An Obese Woman With Worsening Midline Back Pain

An obese woman in her thirties with a history of fibromyalgia syndrome (FMS), depression, polycystic ovarian syndrome, and diabetes mellitus (DM) presents to her local emergency department (ED) with 1 week of gradually worsening midline back pain. At first she thought the pain was a result of her FMS, but because it did not improve after a few days like it usually does, she saw a chiropractor, which also did not help. She finally went to her regular doctor, who prescribed hydrocodone/acetaminophen and cyclobenzaprine; neither has helped her.

Over the past 24 hours, the patient has been constipated and has had difficulty with urinating. Both legs have started to feel “wobbly” and numb. The pain extends from below her neck down to her waist in the midline; it seems to move around some but usually is worst “just above her bra strap.”

The patient has no additional complaints and states that this episode definitely is not like her typical FMS attack. When asked specifically, she denies fever, abdominal pain, and vomiting.

On physical examination, the patient’s pulse is 91 beats per minute; blood pressure, 138/76 mm Hg; respirations, 22 breaths per minute, with a pulse oximeter reading of 99%; and temperature, 37.4°C (99.4°F) taken orally.

Findings from inspection of the patient’s head and neck are unremarkable, but the astute doctor, suspecting the worst, checks for meningismus. The presence of fever and back pain indicates that she has it. Her chest examination findings are completely normal. Her back and flank areas are not particularly tender and neither is her abdomen, but she is quite obese.

Findings from the rest of the examination are unremarkable except for the neurological examination, which shows subjective decreased pinprick sensation in both legs and even up to the lower abdomen. The patient has normal distal leg strength with both plantar flexion and dorsiflexion of the foot, but when she undergoes a straight-leg raise test, she can keep her heels up for only 1 or 2 seconds.

A spinal MRI scan is ordered, but the radiologist refuses to call in the techs for an after-hours MRI scan without doing a CT scan first. He states that a CT scan of the spine will pick up “anything of consequence,” and if the results are negative, they can always do an MRI tomorrow “if indicated.”

A cut from the CT scan at the level of maximal pain is shown here. What do you see? What should you do next?

Please click here for the answer and discussion.