My patient with low back pain was just diagnosed with a lumbar spinal epidural abscess. Should I order an MRI of the rest of the spine?

First, look closely for any signs or symptoms which may suggest cord involvement due to spinal epidural abscess (SEA) at other levels of the spine (in this case cervical or thoracic) which would necessitate an urgent MRI. Be particularly on the lookout for new pain (particularly radicular) or paresthesias involving the abdomen, chest or upper extremities (with or without weakness)1.

Otherwise, whether an MRI of the entire spine should be routinely obtained after a diagnosis of SEA in the absence of any suggestive signs or symptoms is less clear, in part related to lack of properly designed studies.1-4

Nevertheless, a retrospective study involving 233 patients with SEA may shed some light on the subject. Based on 22 cases of noncontiguous SEA (9.4% of total), the following independent risk factors were identified3:

  • Delay in presentation (≥1 week of symptoms)
  • Concomitant area of infection outside the spine and paraspinal region
  • ESR > 95 mm/h at presentation

Probability of non-contiguous SEA based on the number of risk factors was as follows:

  • 3 risk factors: 73%
  • 2 risk factors: 13%
  • 1 risk factor: 2%
  • Zero risk factor: 0%

Despite several shortcomings and the need to confirm its findings2,3, this study helps raise awareness of the potential for concurrent but asymptomatic SEA elsewhere in the spine whenever SEA is diagnosed.

 

References

  1. Bond A, Manian FA. Spinal epidural abscess: a review with special emphasis on earlier diagnosis. BioMed Res International 2016;Volume 2016, Article ID 1614328. https://www.hindawi.com/journals/bmri/2016/1614328/
  2. Schoenfeld AJ, Hayward RA. Predicting modeling for epidural abscess: what we can, can’t, and should do about it. Spine J 2015;15:102-104. http://www.sciencedirect.com/science/article/pii/S152994301401554X
  3. Ju KL, Kim SD, Melikian R, et al. Predicting patients with concurrent noncontiguous spinal epidural abscess lesions. Spine J 2015;15:95-101. https://www.ncbi.nlm.nih.gov/pubmed/24953159
  4. Pfister HW, vonRosen F, Yousry T. MRI detection of epidural spinal abscesses at noncontiguous sites. J Neurol 1996;243:315-7. https://www.ncbi.nlm.nih.gov/pubmed/8965103
My patient with low back pain was just diagnosed with a lumbar spinal epidural abscess. Should I order an MRI of the rest of the spine?

Where should I expect to hear radiation of mitral regurgitation in my patient with endocarditis?

 

Mitral regurgitation (MR) murmur can radiate to several places on the chest wall as well as the spine and….ready for this…. the top of the head!

Classically, MR is thought to have 4 patterns of radiation1,2

  1. Axilla and the inferior angle of the left scapula (typical)
  2. Left sternal border, base of the heart and into the neck
  3. Cervical and lumbar spine (down to sacrum)
  4. Right of the sternum (associated with a “giant left atrium”)

Less well-known and perhaps most intriguing is the radiation of MR to the top of the head. Original reports involved patients who often had ruptured chordae tendineae due to subacute bacterial endocarditis and/or rheumatic heart disease2.

It was posited that “the flail portion of the mitral valve folds back into the left atrial cavity forming a hood which deflects the regurgitant stream against the atrial wall”.  In the setting of a flail anterior leaflet, if the jet stream is sufficiently high energy and comes in contact with the spine, the murmur may be transmitted by bone conduction to the top of the skull2

I suggest you explain to your patient what you are doing before you auscultate the top of their heads!

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References

  1. Chatterjee K. Physical examination. In Topol EJ, ed. Textbook of cardiovascular medicine, 2007, pp 193-224. Lippincott, Williams &Wilkins. Philadelphia. https://books.google.com/books?id=35zSLWyEWbcC&pg=PA219&lpg=PA219&dq=top+of+the+head+mitral+regurgitation+murmur&source=bl&ots=56Erim4eNM&sig=82TrOiU52ojmhVBMG7G2jMULxVo&hl=en&sa=X&ved=0ahUKEwit8_WnmorVAhVGyj4KHcwUC_8Q6AEIRzAF#v=onepage&q=top%20of%20the%20head%20mitral%20regurgitation%20murmur&f=false
  2. Merendino KA, Hessel EA. The “murmur on top of the head” in acquired mitral insufficiency: Pathological and clinical significance. JAMA 1967;199:892-896. http://jamanetwork.com/journals/jama/article-abstract/663746
Where should I expect to hear radiation of mitral regurgitation in my patient with endocarditis?