Case 10: Back Pain
Diabetes and Back Pain
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An obese woman in her thirties with a history of fibromyalgia, depression and diabetes presents with one week of back pain. At first she thought it was her fibromyalgia but it didn’t improve so she saw a chiropractor and then was treated by her doctor with Vicodin and Flexiril, neither of which helped. Over the last 24hours she has been constipated and had trouble urinating and following that both legs started to feel “wobbly” and numb up to her abdomen. The pain is all over and migrates, but is worst “just above her bra strap”.
On exam she has a temperature of 99.4 with otherwise normal vital signs. The astute doctor, suspecting the worst checks for meningismus. She has it. The rest of the exam is unremarkable except for her obesity and the neurologic exam which shows subjective decreased pinprick sensation in both legs but normal distal leg strenght(plantar and dorsi-flexion). However when the patient does a straight leg raise she can only keep her heels up for 1-2 seconds.
The radiologist refuses to call in the techs for an MRI and recommends a CT first. He states that a CT scan of the spine will pick up “anything of consequence” and if it is negative they can always do an MRI tomorrow “if indicated”. The CT is shown below. What do you see? What should you do next?
(Scroll down for answer)
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ANSWER:
You can’t see enough. This test is inadequate. You need and MRI (below) which showed a spinal epidural abscess. Diabetes was this patient’s only risk factor. Her presentation, including the initial miss, is fairly classic.
Excerpt on Epidural Abscess from “Quick Essentials“
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Sx/Sn: Often delayed Dx b/c insidious: mild pain > F > root > menigismus & rapid cord syndrome
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RF: CVC, even remote IVDA, recent OR/LP,
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Tests: CT:50(but fast,better ? contrast), ESR:95+, MRI:90+ but slower. DDx: Psoas/deep neck abscess
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Rx: OR stat! ? thoracic. ABX: Rocephin, Clinda, Vanco. (steroids: ask consultant)
Im(DM,CA,sroid,EtOH), ID(UTI,PNA,neck furuncle)