Critical Cases - Epidural Abscess Emergency!

CC: Back pain

HPI: 61 yo M with PMHx DM, HTN, HCV c/o lower back pain x 2 days. The pain is located bilat but L>R and radiates down his LLE. Described as 9/10 and sharp/shooting.  Seen two days ago and had CT T and L spine that showed herniated discs and neural foraminal stenosis.  Taking acetaminophen without relief. Denies F/C/N/V/D/CP/SOB or upper back pain. . Pain is better when laying flat. Denies saddle paresthesias,  leg numbness/weakness, difficulty urinating, urinary or fecal incontinence. Denies recent infection, no hx of cancer, and no IVDU. In 2006 he suffered a severe back injury after falling in a hole- was diagnosed with herniated discs at that time. Works as a trash collector.


VS: BP  149/107 | Pulse 134 | Temp 99.5 °F (37.5 °C) (Oral) | Resp 18 | SpO2 97%

Cardiovascular: Reg rhythm, tachycardic, no murmur.

Pulmonary/Chest: Clear

Abdominal: Soft and nontender

Musculoskeletal:+b/l T anbd L paraspinal TTP 

Rectal: normal rectal tone, no prostate tenderness

Neurological: He exhibits normal muscle tone. 5/5 strength  BLE but severe pain with movement of LLE and +straight leg raise test.



  • Sciatica secondary to known herniated discs 
  • Spinal stenosis
  • Osteomyelitis/discitis/epidural abscess
  • Epidural hematoma
  • Pathologic fracture
  • Consider: AAA/dissection (HTN, smoker, male), nephrolithiasis/pyelonephritis



  • CBC/chem/ua all unremarkable
  • CT a/p to assess for ureterolithiasis: negative
  • Rpt vitals: T 102.1F  HR 120s
  • MRI of his T and L spine: Epidural abscess T11/T12
  • Neurosurg consult: to OR for decompressive hemilaminectomy
  • Cultures grew MSSA



  • Back pain usually benign, until it is not
  • Beware bouncebacks: intensify workup on second visit, consider consultation and/or admission
  • Spinal epidural abscesses most common complaints in decreasing order: back pain > fever > focal neuro deficit; triad only in 8-37% of patients
  • MRI is the study of choice for high clinical suspicion
  • TIME IS OF THE ESSENCE → neuro outcome is correlated with degree of deficit prior to NSG intervention


Reference: Tanski ME and Ma OJ. Central Nervous System and Spinal Infections. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill.