August ’12

Medical Student Elective
Case of the Month
August
Submitted by: Mallory Glass, MS4 University of Florida

HPI
66yo female presents s/p C7-T1 epidural cortisone injection for chronic degenerative disk disease. Pt states that injection occurred at 10am and around 11:30am she started experiencing neck pain while trying to eat cereal. The pain became severe over the next hour until an ambulance was called. The pain is located from just above injection site to mid-thoracic region, increases with sitting up/standing up, and is accompanied by numbness/tingling down both arms. Pain is 8/10. She denies any HA, weakness, fever/chills, vision changes, hearing changes, CP, SOB, abdominal pain, N/V, urinary or fecal incontinence. No hx of cervical or thoracic spine surgery, diskitis, or IVDU.


PMH
CAD, hepatitis C, hypercholesterolemia, osteoporosis, degenerative disk disease, macular degeneration.
Social history: None Relevant.


Meds
ASA 81mg, Cozaar, Lovaza, Simvastatin, vitamin D, Coenzyme Q10, Ocuvite Lutein


Allergies
Codeine, Compazine, Ultram


PE (pertinent)
When pt came in she was curled up on all fours in tight fetal position, in tears.
Vitals: Oral temp 97.4, BP 155/87, HR 75, RR 16, SpO2 99%
Constitutional: Alert, oriented, in NAD, cooperative, uncomfortable
HEENT: NC/AT, EOMI, PERRL, moist mucous membranes
Neck: TTP over epidural block site, otherwise no midline tenderness, fluctuance, or mass. Full ROM. Supple.
Cardio: NRRR, nl S1/S2, no M/G/R
Resp: CTAB, breath sounds equal b/l, no wheezes/rhonchi/rales
GI: NABS, soft, non-tender, non-distended, no masses or HSM
Ext: Skin warm with good color. 2+ distal pulses in all extremities, no edema
Neuro: AOx3, CN’s II-XII intact, normal speech, normal coordination, strength 5/5 and symmetric in UE’s and LE’s, subjective paresthesias in lateral upper and lower arms extending in ulnar distribution.

LABS
CBC – WBC 6.4 (86.5% N, 11.8% L), Hgb 14.4, Hct 44.8, Plts 296
BMP – Na 140, K 4.9, Cl 107, CO3 20, BUN 17, Cr 0.5, Glu 117
Coags – PT 13.4, INR 1.0, aPTT 27.5


MRI C-Spine
“Findings consistent with a posterior epidural hematoma most prominent at C7, where there is mild to moderate canal stenosis and cord deformity, but no abnormal cord signal.”


What is the most likely diagnosis for this patient?


Progress

  • Pt was given 8mg Morphine with much improved pain and somewhat improved paresthesias.
  • Spoke with pain management doctor who had performed injection.
  • Consulted NSG –> Decision to do MRI
  • After MRI results: decision to give 2 units of platelets because pt on ASA. Also given 10mg dexamethasone because of spinal cord compression.
  • Dispo: admitted to NSG for serial exams vs. decompression as needed. No need for immediate decompression because no focal neurologic deficits.
  • Ultimately decided to transfer to Cornell hospital by pt’s request because her cardiologist and other doctors are there.


What is the most likely diagnosis for this patient?
Spinal Epidural Hematomas


Take home messages

  • Spinal epidural hematomas can be traumatic (lumbar puncture, epidural anesthesia) or spontaneous.
  • Spontaneous causes include: anticoagulation, thrombolysis, blood dyscrasias, coagulopathies, thrombocytopenia, neoplasms, or AVMs.
  • Usually involves peridural venous plexus; rarely arterial sources.
  • 1 in 1,000,000 people annually
  • Presentation: severe localized back pain with delayed radicular radiation of pain/paresthesias. Can mimic disk herniation. Associated symptoms: weakness, numbness, urinary/fecal incontinence.
  • Incidence of spinal hematoma after epidural anesthesia is 1 in 150,000
  • Factors that increase the risk: advanced age, female gender, multiple attempts, and coagulopathy.


Sources
Tam N, Pac-Soo C, Pretorius P. Epidural haematoma after a combined spinal–epidural anaesthetic in a patient treated with clopidogrel and dalteparin. Br. J. Anaesth. 2006; 96: 262-265.
Liebeskind, David. Epidural Hematoma. Medscape Reference 2012. http://emedicine.medscape.com/article/1137065-overview/



Every month during director’s rounds, our students present interesting and educational cases. This is a synopsis of the case voted to be the best by the students and directors at the end of director’s rounds along with an interesting image.


OR


Program Directors

Jennifer Stratton, MD and Patricia Van Leer, MD
slredmedstuds@yahoo.com
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