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Difficulty: HardPreoperative and Postoperative Care

A 62-year-old man is evaluated in the surgical ward on postoperative day 5 following an open anterior resection for severe rectal prolapse. Postoperative pain was managed with a lumbar epidural catheter, which was removed yesterday. He had been ambulating with assistance and tolerating a soft diet. Over the past 12 hours, he has developed a fever, chills, and increasing lower back pain. His temperature is 38.9°C (102.0°F), pulse is 110/min, respirations are 18/min, and blood pressure is 118/72 mm Hg. Physical examination reveals exquisite tenderness to palpation over the lower lumbar spine. Neurologic examination demonstrates 3/5 motor strength in the bilateral lower extremities and diminished sensation to pinprick below the L2 dermatome. A bedside bladder ultrasound reveals 600 mL of urine, despite the patient reporting no urge to void. The abdominal incision is clean, dry, and intact with no erythema or fluctuance. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography of the abdomen and pelvis
  2. B
    Empiric administration of broad-spectrum intravenous antibiotics
  3. Magnetic resonance imaging of the lumbar spineAnswer
  4. D
    Urinalysis and urine culture
  5. E
    Lower extremity venous duplex ultrasonography

Answer

Magnetic resonance imaging of the lumbar spine
This patient presents with a high fever, severe localized lower back pain, and new-onset neurologic deficits (lower extremity weakness, urinary retention) on postoperative day 5. Given his recent use of a lumbar epidural catheter for pain management, this clinical triad is highly suspicious for a spinal epidural abscess (SEA). SEA is a rare but potentially devastating complication of neuraxial anesthesia and analgesia. The infection typically spreads from the skin insertion site into the epidural space, leading to an expanding suppurative collection that compresses the spinal cord or cauda equina. Immediate evaluation is required to prevent irreversible paralysis. The most appropriate next step in management is a magnetic resonance imaging (MRI) scan of the spine with gadolinium. MRI is the gold standard for visualizing the epidural space, determining the extent of the abscess, and planning for urgent neurosurgical decompression and drainage.

Step-by-Step Solution

1
Analyze the patient's timeline and clinical presentation.
The patient developed a fever, localized severe back pain, lower extremity weakness, and urinary retention one day after the removal of a lumbar epidural catheter.
Establishing the sequence of events (epidural removal followed by progressive neurologic and infectious signs) is crucial for identifying iatrogenic complications.
2
Synthesize the findings into a unifying diagnosis.
The classic triad of fever, focal spinal tenderness, and neurologic deficits (motor weakness, neurogenic bladder) strongly suggests a spinal epidural abscess.
An epidural abscess is a known, severe complication of neuraxial anesthesia that requires immediate recognition to prevent irreversible paralysis.
3
Determine the most appropriate immediate diagnostic step.
Magnetic resonance imaging (MRI) of the spine with gadolinium is selected.
MRI is the gold standard test to visualize the epidural space, confirm the presence and extent of the abscess, and guide urgent neurosurgical intervention.

Key Concept

Diagnosis and management of spinal epidural abscess as a complication of postoperative epidural analgesia.
Estimated Time:1m 30s
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Topics

Preoperative and Postoperative Care

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