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Diagnosis and Discussion: Interscapular Pain
The final diagnosis and a discussion of reader responses
In the case of the patient with interscapular pain (JW Neurol Mar 31 2009), the treating clinician initially suspected that the cause of the myelopathy was ischemic, given that the patient has diabetes and atrial fibrillation. However, inflammatory markers were significantly elevated. The local spinal tenderness was important. The MRI scan showed an extradural abscess extending from cervical level 5 to thoracic level 9 (see image). During surgery, pus was drained from the extradural space, from which Staphylococcus aureus was cultured. Postoperatively, the patient received antibiotics and neurological improvement was noted 1 week later.
Lessons learned: The diagnosis of myelopathy was delayed because the symptoms could not be localized to a specific sensory level and because upper motor neuron signs were initially subtle. The elevated inflammatory markers were the clue to the inflammatory pathology. The absence of pyrexia with spinal abscess has been described, but the patient had back pain and local spinal tenderness, which are characteristic features of an epidural abscess. In 21% of spinal abscesses, diabetes is a predisposing condition, and in another 30% to 40%, no source of infection is found, but skin sepsis is a common cause (Neurosurg Rev 2000; 232:175).
Comment on Reader Responses: We are delighted with the enthusiastic reader responses. More than 25% correctly diagnosed an epidural abscess. Almost 50% incorrectly favored some type of spinal cord ischemia. A minority suspected a malignancy. The absence of a sensory level goes against an intramedullary lesion such as ischemia. The features pointing to an epidural abscess are the local spinal tenderness, markedly raised inflammatory markers, presence of diabetes, and extramedullary myelopathic signs.
Published in Journal Watch Neurology April 28, 2009
Reader Remarks:
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- Missed Easily
Rabia Akbar Vali, C.P.H., 29 Apr 2009 10:41 AM EST
one has to always remember to put the clinical examination and lab results together to draw a conclusion and avoid... [more]
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