History: A 39-year-old male with a history of hepatitis C and polysubstance abuse presents with acute onset lower extremity paralysis and paresthesia, bilateral upper extremity weakness, and diffuse neck pain. He admits to falling from a standing height about 1 week prior, but states he was seen at another facility and discharged in good condition except for persistent neck pain. Review of systems is otherwise negative, and the patient has no previous history of similar episodes.
Physical Exam: Afebrile, well appearing, with normal vital signs. Physical examination is normal except for the following abnormal neurological findings: exquisite tenderness to palpation at C6 spinous process, bilateral upper extremity weakness (2/5) with normal deep tendon reflexes, bilateral lower extremity paralysis (0/5) with absent deep tendon reflexes, weakness of grip strength bilaterally, normal tone, and Babinski negative bilaterally. Ambulation and gait cannot be tested. Finger-to-nose testing is normal. Proprioception is intact bilaterally. There is absent perineal sensation. Weak contracture of the anal sphincter noted, but no bulbocavernosus reflex could be elicited.
Management: Laboratory studies and chest x-ray are normal. CT scan of head and cervical spine demonstrate no intracerebral abnormality but do show degenerative changes of the spine, most prominent at the C4-C7 levels; the canal diameter, however, is normal.
Neurosurgical consultation is requested for persistent lower extremity paralysis. An MRI is ordered, and high-dose methylprednisolone intravenous infusion started. The MRI reveals pre-vertebral soft tissue swelling from C2-C7 and increased T2-signal extending from C5-C6 within the epidural space and extending posteriorly 5 mm. There is associated cervical cord compression suggesting early abscess formation. The patient is taken for emergent neurosurgical decompression and drainage. Cultures were positive for Staphylococcus aureus. Patient is discharged home 15 days later able to ambulate but with residual lower extremity weakness.
Back pain is second only to respiratory complaints as a reason for primary care visits, with 90%-95% having a non-life–threatening condition1,2 and 85% recovering in 4-6 weeks without intervention.1-3 The other 5%-10% of cases, however, may harbor a more serious pathology and warrant further diagnostic evaluation in the emergency department.