A 59-year-old man comes to the emergency department due to a sore throat. He says that he was assaulted during an altercation in a bar 7 days ago. The following day, the patient noticed some neck pain and stiffness, followed by a sore throat. Today, he has severe throat pain, which has spread to his left shoulder and radiates down his left arm. The patient drinks 6-12 beers daily and has a 50-pack-year smoking history. Medical history includes type 2 diabetes mellitus and hypertension. Temperature is 38.6 C (101.5 F), blood pressure is 108/70 mm Hg, pulse is 106/min, and respirations are 16/min. On examination, the patient is awake and alert. Abrasions are present on the head, neck, and face. Mild swelling and ecchymosis are noted on the forehead and around the right eye. The posterior pharynx is normal; there is no trismus or drooling. Right upper extremity strength is 5/5, and left upper extremity strength is 4/5. Cervical spine tenderness is present at the C5 and C6 level. Laboratory results are as follows:
| Hemoglobin | 11 g/dL |
| Platelets | 260,000/mm3 |
| Leukocytes | 16,300/mm3 |
What is the best next step in management of this patient?
Show Explanatory Sources
Features of this patient's presentation suggest spinal epidural abscess (SEA). He has conditions that lead to an immunocompromised state (eg, diabetes mellitus, alcohol use), and he was assaulted. Trauma is a significant risk factor for SEA via development of a hematoma that may expand and become infected. This patient's neck pain and stiffness progressed over days to include a sore throat (from extension of the abscess into the retropharyngeal space) and radiating pain. He had fever and focal neurologic findings (eg, weakness of left upper extremity); laboratory analysis revealed leukocytosis.
The classic triad of SEA includes the following:
Spinal pain, often focal with progression to radiculopathic pain (eg, radiating, shooting, electric-shock sensation)
Neurologic deficits, often progressive as the abscess expands and referable to the level of compression (eg, weakness, sensory changes, bowel/bladder dysregulation)
Fever (~50% of patients)
All are present in a minority of patients. Fever is most commonly absent, but patients often have other signs of infection (eg, leukocytosis, elevated erythrocyte sedimentation rate). MRI of the cervical spine with contrast should be performed because it can show early evidence of the presence and extent of infection that often cannot be seen with CT scan or plain x-rays.
(Choice A) Contrast esophagography (using water-soluble contrast) can demonstrate esophageal rupture, which can occur after blunt trauma, causing pain, tachycardia, and leukocytosis. Esophageal rupture typically presents within a few hours with signs of gastric contents leaking into the chest or neck (eg, pleural effusion, neck crepitus).
(Choice B) CT scan of the head can visualize intracranial hemorrhage, which can present with focal neurologic deficits, often due to head trauma. Traumatic intracranial hemorrhage typically presents within hours of injury (vs 7 days), and patients typically have altered mental status. Sore throat and radicular pain would not be present.
(Choice C) Direct laryngoscopy may reveal evidence of retropharyngeal swelling. Although this patient's abscess may extend into the retropharyngeal space, which can cause fever, throat pain, and leukocytosis, neurologic symptoms and radiculopathic pain suggest involvement beyond the retropharyngeal space.
(Choice D) Blunt cerebrovascular injury (eg, carotid dissection) can present with neck pain and delayed neurologic deficits following trauma; radiculopathic pain, sore throat, fever, and leukocytosis are not typically present. CT angiography is preferred over MR angiography of the neck vessels because of its faster speed and decreased costs.
Educational objective:
Spinal epidural abscess can occur due to trauma, especially in immunocompromised patients. Manifestations include progressive worsening of pain, neurologic deficits, and systemic inflammatory signs (eg, fever, leukocytosis).