Cauda Equina Syndrome Case Summary

A 59-year old white female presented to the Emergency Room department complaining of severe back pain that began two days prior. The patient was tender to the touch along the middle of the thoracic spine with no warmth or redness. The patient’s spine did reveal mild scoliosis but no gross deformities. There was no significant radiating pain to the surrounding spinal musculature. Although the patient was ambulatory, any movement such as walking, twisting side to side, bending over, or standing up inflicted pain. The patient did not recall any instance in which she strained or injured her spine lifting or any recent coughing episodes. The patient denies having a fever but stated she has had chills and headaches daily for at least a week. Patient stated she usually has intermittent headaches but recent headaches have been more severe and frequent. Patient denies any chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, or constipation. There was no loss of sensation to the buttocks, perineum, and inner thigh ruling out cauda equina syndrome.
Medical History
The patient has an extensive medical history including chronic abdominal pain and hypomagnesia due to short bowel syndrome (SBS), chronic mycobacterium avium complex infection, chronic kidney …show more content…
The MRI results could not conclusively diagnose discitis versus degenerative discogenic disease. The ER doctor believed this to be a case of just discogenic disease as the patient was not febrile and her WBC count was normal. However, the ER doctor was concerned the patient’s hs-CRP and sedimentation rate was elevated which also hinted at possible early discitis. The patient was discharged from the ER with a prescription for Percocet and instructed to follow up with a neurosurgeon in six days or return to the hospital if symptoms worsened or if fever