Upper cervical epidural abscess with emphasis on diabetes as a risk factor: a case report.

BACKGROUND: An upper cervical spine epidural abscess (UCEA) is an epidural abscess that develops in the area between the occiput and the second cervical spine (axis). It is a rare diagnosis that carries the risk of instability of the atlantoaxial joint, and its management is not well-defined. It is known that the skin is the most common source of infection, and that diabetes mellitus (DM) is the most frequently reported risk factor. In this case, we present a patient diagnosed with UCEA, who achieved full neurological recovery postoperatively despite having neurological deficits for over five days prior to surgery. CASE PRESENTATION: We report the case of a 56-year-old male patient with no history of any prior medical conditions, who presented with headache, neck pain, and weakness of the left side. The weakness started approximately three days prior to his presentation. His initial work up revealed hyperglycemia and elevated HbA1c of 86 mmol/mol (10%). Magnetic resonance imaging (MRI) of the cervical spine revealed spondylitis of the C2 spine with an abscess at the craniocervical junction. He underwent a two-staged surgical approach: decompression and stabilisation. The patient achieved full motor recovery approximately three months postoperatively. CONCLUSIONS: We recommend screening for DM when a spinal epidural abscess (SEA) is diagnosed without readily identifiable risk factors. The optimal management in most SEA cases is surgical, which is particularly true for UCEA because of the risk of atlantoaxial joint instability. Full neurological recovery is possible even when the patient has been having deficits for more than five days.

Neisseria gonorrhoeae cervical spine epidural abscess requiring spinal decompression and instrumented fusion.

Disseminated gonococcal infection (DGI) is an uncommon complication of Neisseria gonorrhoeae infection, and typically presents with either a triad of tenosynovitis, dermatitis and polyarthralgia, or with extra-axial large joint septic arthritis. Spinal epidural abscess is a rare manifestation of DGI, with only a few previously reported cases, none of which required placement of metalware into the infected space. Here we report a severe case of isolated N. gonorrhoeae cervical spine epidural abscess necessitating surgical source control (C7/T1 laminectomy and debridement) and metalware placement (C6-T2 posterior instrumented fusion). The case was successfully managed by a combination of surgical intervention followed by six weeks of predominantly oral, targeted antimicrobial therapy.

Comparison of endoscopic sinus sampling versus intracranial sampling for microbiological diagnosis of intracranial infection in children: a case series and literature review.

INTRODUCTION: Intracranial infection is often associated with contiguous sinus infection, with Streptococcus intermedius being the most common pathogen. Microbiological assessment is possible via sinus or intracranial sampling. While a sinus approach is minimally invasive, it is not clear whether this yields definitive microbiological diagnosis leading to optimized antimicrobial therapy and avoidance of intracranial surgery. METHODS: A retrospective review of a prospectively collected electronic departmental database identified patients between 2019 and 2022. Further demographic and microbiological information was obtained from electronic patient records and laboratory management systems. RESULTS: Thirty-one patients were identified with intracranial subdural and/or epidural empyema and concurrent sinus involvement during the 3-year study period. The median age of onset was 10 years with a slight male predominance (55%). All patients had intracranial sampling with 15 patients undergoing sinus sampling in addition. Only 1 patient (7%) demonstrated identical organism(s) grown from both samples. Streptococcus intermedius was the most common pathogen in intracranial samples. Thirteen patients (42%) had mixed organisms from their intracranial cultures and 57% of samples undergoing bacterial PCR identified additional organisms, predominantly anaerobes. Sinus samples had a significant addition of nasal flora and Staphylococcus aureus which was rarely grown from intracranial samples. Of concern, 7/14 (50%) of sinus samples did not identify the main intracranial pathogen diagnosed on intracranial culture and additional PCR. Literature review identified 21 studies where sinus drainage was used to treat intracranial empyemas, with only 6 authors reporting concurrent microbiology results. This confirmed our cohort to be the largest comparative study in the current literature. No center has observed a greater than 50% concordance in microbiological diagnoses. CONCLUSION: Endoscopic sinus surgery may have therapeutic benefit, but it is not an appropriate approach for microbiological diagnosis in pediatric subdural empyemas. High rates of contaminating nasal flora can lead to misdiagnosis and inappropriate treatment. Routine addition of 16S rRNA PCR to intracranial samples is recommended.

Mortality, complication risks, and clinical outcomes after surgical treatment of spinal epidural abscess: a comparative analysis of patients aged 18-64 years, 65-79 years, and ≥ 80 years, with a 3-year follow-up.

Spinal epidural abscess (SEA) with pyogenic vertebral osteomyelitis (PVO) is a rare illness with a steadily increasing incidence. However, comparative analyses of young and older patients with SEA are lacking. We aimed to compare the clinical course of patients aged 18-64 years, 65-79 years, and ≥ 80 years undergoing surgery for SEA. Clinical and imaging data were retrospectively collected from the institutional database between September 2005 and December 2021. Ninety-nine patients aged 18-64 years, 45 patients aged 65-79 years, and 32 patients ≥ 80 years were enrolled. Patients ≥ 80 years presented with a poorer baseline history (9.2 ± 2.4), as indicated by the CCI, than their younger counterparts (18-74 years: 4.8 ± 1.6;6.5 ± 2.5; p < 0.001). Patients aged 65-79 years and 80 years had a significantly longer length of stay. In-hospital mortality was significantly higher in those aged ≥ 80 years compared to their younger counterparts (≥ 80 years, n = 3, 9.4% vs. 18-64 years, n = 0, 0.0%; 65-79 years, n = 0, 0.0%; p < 0.001), while no differences in 90-day mortality or 30-day readmission were observed. After surgery, a significant decrease in C-reactive protein levels and leukocytes and amelioration of motor scores were observed in all the groups. Of note, older age (> 65 years), presence of comorbidities, and poor preoperative neurological condition were significant predictors of mortality. Surgical management led to significant improvements in laboratory and clinical parameters in all age groups. However, older patients are prone to multiple risks, requiring meticulous evaluation before surgery. Nevertheless, the risk profile of younger patients should not be underestimated. The study has the limitations of a retrospective design and small sample size. Larger randomized studies are warranted to establish the guidelines for the optimal management of patients from every age group and to identify the patients who can benefit from solely conservative management.

Spinal epidural abscess as predicting factor for the necessity of early surgical intervention in patients with pyogenic spondylitis.

BACKGROUND: Pyogenic spondylitis is a condition with low incidence that can lead to neurological sequelae and even life-threatening conditions. While conservative methods, including antibiotics and bracing, are considered the first-line treatment option for pyogenic spondylitis, it is important to identify patients who require early surgical intervention to prevent progressive neurologic deficits or deterioration of the systemic condition. Surgical treatment should be considered in patients with progressive neurologic deficits or deteriorating systemic condition. However, currently, there is a lack of treatment guidelines, particularly with respect to whether surgical treatment is necessary for pyogenic spondylitis. This study aims to analyze the radiological epidural abscess on MRI and clinical factors to predict the need for early surgical intervention in patients with pyogenic spondylitis and provide comprehensive insight into the necessity of early surgical intervention in these patients. METHODS: This study retrospectively reviewed 47 patients with pyogenic spondylitis including spondylodiscitis, vertebral osteomyelitis, epidural abscess, and/or psoas abscess. All patients received plain radiographs, and a gadolinium-enhanced magnetic resonance imaging (MRI) scan. All patients have either tissue biopsies and/or blood cultures for the diagnosis of a pathogen. Demographic data, laboratory tests, and clinical predisposing factors including comorbidities and concurrent other infections were analyzed. RESULTS: We analyzed 47 patients, 25 of whom were female, with a mean age of 70,7 years. MRI revealed that 26 of 47 patients had epidural abscesses. The surgical group had a significantly higher incidence of epidural abscess than the non-surgical group (p = 0.001). In addition, both CRP and initial body temperature (BT) were substantially higher in the surgical group compared to the non-surgical group. There was no significant difference between the surgical group and the non-surgical group in terms of age, gender, comorbidities, and concurrent infectious disorders, as well as the number of affected segments and affected spine levels. However, the surgical group had lengthier hospital stays and received more antibiotics. CONCLUSION: The presence of an epidural abscess on MRI should be regarded crucial in the decision-making process for early surgical treatment in patients with pyogenic spondylitis in order to improve clinical outcomes.

Epidural Abscesses as a Complication of Interleukin-6 Inhibitor and Dexamethasone Treatment in a Patient with COVID-19 Pneumonia: A Case Report.

A 66-year-old female patient was hospitalized with severe COVID-19 pneumonia, which led to hypoxia requiring oxygen support with high-flow nasal cannulae. She received anti-inflammatory treatment with a 10-day dexamethasone 6 mg PO course and a single infusion of IL-6 monoclonal antibody tocilizumab 640 mg IV. Treatment led to gradual reduction of oxygen support. However, on Day 10, she was found to have Staphylococcus aureus bacteremia with epidural, psoas, and paravertebral abscesses as the source. Targeted history taking revealed a dental procedure for periodontitis 4 weeks prior to hospitalization as the probable source. She received an 11-week antibiotic treatment, which led to resolution of the abscesses. This case report highlights the importance of individual infection risk assessment before the initiation of immunosuppressive treatment for COVID-19 pneumonia.

[Febrile cervicalgia revealing infectious epiduritis : a case report]. / Cas clinique. Cervicalgies fébriles révélatrices d'une épidurite infectieuse.

Infectious epiduritis and epidural abscesses are relatively rare pathologies but with important neurological consequences. A low incidence associated with an insidious clinical presentation leads to frequent delays in diagnosis, which worsen the prognosis of patients with the development of neurological deficits. While the evaluation of risk factors, a careful clinical examination and biological tests can guide to the diagnosis, the key examination remains magnetic resonance imaging (MRI) while lumbar puncture remains contraindicated. Although surgery (spinal decompression) has long been the treatment of choice, the current management of patients with infectious epiduritis is debated between surgery and conservative treatment with systemic antibiotic therapy.

Les épidurites infectieuses et les abcès épiduraux sont des pathologies relativement rares, mais avec des conséquences neurologiques redoutables. Une faible incidence et une présentation clinique souvent insidieuse engendrent de fréquents retards de diagnostic qui péjorent le pronostic des patients avec le développement de déficits neurologiques. Si l'évaluation des facteurs de risque, un examen clinique scrupuleux et des analyses biologiques peuvent guider vers le diagnostic, l'examen-clé reste l'imagerie par résonance magnétique (IRM). La ponction lombaire est contre-indiquée. Bien que l'approche chirurgicale ait longtemps été le traitement de choix, un traitement plus conservateur basé sur une antibiothérapie systémique est également discuté.

Oral sequential therapy in the treatment of post-surgical epidural abscess and subdural empyema.

PURPOSE: The management of post-surgical subdural empyema and subdural abscess is not standardised. The objective was to analyse the efficacy and safety of oral sequential therapy (OST). METHODS: Retrospective observational study in a tertiary hospital in Vigo (Spain). We included adult patients with subdural abscess or epidural empyema with microbiological isolation. Clinical and demographic variables, isolated microorganisms and treatment regimens were included, as well as mortality and adverse effects during the follow-up period. RESULTS: Thirty patients were reviewed, two died due to causes other than infection. Six-month recurrence rate was 2/28 and all other patients (26/28) had clinical cure at the end of the treatment. The commonest isolated microorganisms were Gram-positive, especially Staphylococcus aureus. The most widely used oral antibiotic was trimethoprim-sulfamethoxazole (80%). No side effects related to oral treatment were observed. CONCLUSION: After adequate source control, OST can be a safe practice in the management of post-surgical epidural abscess and subdural empyema.

Campylobacter coli infection causes spinal epidural abscess with Guillain-Barré syndrome: a case report.

BACKGROUND: Guillain-Barré syndrome (GBS) and spinal epidural abscess (SEA) are known as mimics of each other because they present with flaccid paralysis following an infection; however, they differ in the main causative bacteria. Nevertheless, the two diseases can occur simultaneously if there is a preceding Campylobacter infection. Here, we report the first case of SEA with GBS following Campylobacter coli infection. CASE PRESENTATION: A 71-year-old Japanese man presented with progressive back pain and paralysis of the lower limbs following enteritis. Magnetic resonance imaging showed a lumbar epidural abscess that required surgical decompression; therefore, surgical drainage was performed. Blood cultures revealed the presence of C. coli. Despite surgery, the paralysis progressed to the extremities. Nerve conduction studies led to the diagnosis of GBS. Anti-ganglioside antibodies in the patient suggested that GBS was preceded by Campylobacter infection. Intravascular immunoglobulin therapy attenuated the progression of the paralysis. CONCLUSIONS: We report a case of SEA and GBS following Campylobacter infection. A combination of the two diseases is rare; however, it could occur if the preceding infection is caused by Campylobacter spp. If a cause is known but the patient does not respond to the corresponding treatment, it is important to reconsider the diagnosis based on the medical history.

Imaging characteristics and CT sensitivity for pyogenic spinal infections.

BACKGROUND/OBJECTIVE: Contrast-enhanced magnetic resonance imaging (MRI) is the preferred imaging modality for diagnosing pyogenic spinal infection (PSI), but it is not always available. Our objective was to describe pyogenic spinal infection imaging characteristics in patients presenting to a community emergency department (ED) and estimate the computed tomography (CT) sensitivity for these infections. METHODS: We examined the MRI reports from a cohort of 88 PSI patients whom we enrolled in a prospective cohort study and report the prevalence of each PSI type (spinal epidural abscess/infection, vertebral osteomyelitis/discitis, septic facet, and paravertebral abscess/infection) according to contemporary nomenclature. In a 14 patient subcohort who underwent both CT and MRI studies, we report the sensitivity for each PSI from a post hoc blinded overread of the CT imaging by a single neuroradiologist. RESULTS: Of the 88 PSI patients, the median age was 55 years, and 31% were female. The PSI prevalence included: spinal epidural abscess/infection (SEA) in 61(69%), vertebral osteomyelitis/discitis (VO/D) in 54 (61%), septic facet (SF) in 15 (17%), and paravertebral abscess/infection (PVA) in 53 (60%). Of the SEAs, 82% (50/61) were associated with other spinal infections, while 18% (11/61) were isolated SEAs. The overall CT sensitivity in a masked overread was 79% (11/14) for any PSI, 83% (10/12) for any infection outside the spinal canal, and only 18% (2/11) for SEA. CONCLUSION: Patients found to have vertebral osteomyelitis/discitis, septic facet, and paravertebral infections frequently had a SEA coinfection. CT interpretation by a neuroradiologist had moderate sensitivity for infections outside the spinal canal but had low sensitivity for SEA.

Cervical Epidural Abscess: A Blind Spot for Postmortem Computed Tomography.

ABSTRACT: Spinal epidural abscess is an uncommon condition, which may have serious complications, including neurological sequelae and death. Classical symptoms include spinal pain, fever, and neurological deficit; however, diagnosis is difficult and requires a high degree of clinical suspicion. Antemortem magnetic resonance imaging (MRI) scanning is the gold-standard diagnostic tool. Computed tomography (CT) is less sensitive and as such, postmortem CT may miss the diagnosis. We report a case of Staphylococcus aureus cervical epidural abscess presenting as neck pain and causing flaccid paralysis and subsequently death. Antemortem MRI showed a small epidural collection, spinal cord edema, and fluid in the adjacent cervical disc and facet joints; however, these findings could not be appreciated on postmortem CT. Postmortem examination, guided by the antemortem imaging, was able to confirm a cervical spinal epidural abscess; however, similar deaths may occur before medical presentation. This case demonstrates a limitation of postmortem imaging in diagnosing spinal epidural abscess and highlights that such cases may be missed.

Pott Puffy Tumor Caused by Dental Infection: A Case Report and Literature Review.

ABSTRACT: Pott puffy tumor (PPT), first described by Sir Percivall Pott in 1760, is a rare clinical entity characterized by a subperiosteal abscess associated with osteomyelitis of the frontal bone caused by direct or hematogenous spread. Although rare in this modern age of antibiotics, this tumor usually occurs as a complication of sinusitis. Moreover, intracranial complications such as subdural abscess, meningitis, sinus thrombosis, or brain abscess can occur concomitantly with the underlying sinusitis, despite the administration of antibiotics. Herein, we present the case of a 48-year-old man who was diagnosed with PPT using computed tomography and treated medically and surgically. The infection remained uncontrollable after surgery and drain removal, owing to the persistence of the original dental focus of the infection. This case highlights the importance of treating the source of the infection in addition to the local area of inflammation, to facilitate complete infection control in PPT.

Acute Symptomatic Seizures in Critically Ill Patients with COVID-19: Is There an Association?

BACKGROUND: The coronavirus disease of 2019 (COVID-19) emerged as a global pandemic. Historically, the group of human coronaviruses can also affect the central nervous system leading to neurological symptoms; however, the causative mechanisms of the neurological manifestations of COVID-19 disease are not well known. Seizures have not been directly reported as a part of COVID-19 outside of patients with previously known brain injury or epilepsy. We report two cases of acute symptomatic seizures, in non-epileptic patients, associated with severe COVID-19 disease. CASE PRESENTATIONS: Two advanced-age, non-epileptic, male patients presented to our northeast Ohio-based health system with concern for infection in Mid-March 2020. Both had a history of lung disease and during their hospitalization tested positive for SARS-CoV-2. They developed acute encephalopathy days into their hospitalization with clinical and electrographic seizures. Resolution of seizures was achieved with levetiracetam. DISCUSSION: Patients with COVID-19 disease are at an elevated risk for seizures, and the mechanism of these seizures is likely multifactorial. Clinical (motor) seizures may not be readily detected in this population due to the expansive utilization of sedatives and paralytics for respiratory optimization strategies. Many of these patients are also not electrographically monitored for seizures due to limited resources, multifactorial risk for acute encephalopathy, and the risk of cross-contamination. Previously, several neurological symptoms were seen in patients with more advanced COVID-19 disease, and these were thought to be secondary to multi-system organ failure and/or disseminated intravascular coagulopathy-related brain injury. However, these patients may also have an advanced breakdown of the blood-brain barrier precipitated by pro-inflammatory cytokine reactions. The neurotropic effect and neuroinvasiveness of SARS-Coronavirus-2 have not been directly established. CONCLUSIONS: Acute symptomatic seizures are possible in patients with COVID-19 disease. These seizures are likely multifactorial in origin, including cortical irritation due to blood-brain barrier breakdown, precipitated by the cytokine reaction as a part of the viral infection. Patients with clinical signs of seizures or otherwise unexplained encephalopathy may benefit from electroencephalography monitoring and/or empiric anti-epileptic therapy. Further studies are needed to elucidate the risk of seizures and benefit of monitoring in this population.

An unusual case of Nocardia cyriacigeorgica presenting with spinal abscesses in a renal transplant recipient and a review of the literature.

Nocardia species represent a well-recognized yet uncommon cause of opportunistic infections in humans. It most frequently presents as a pulmonary infection with or without central nervous system involvement. It is a very rare cause of spinal abscesses, with only 26 cases reported in the literature. Here we report a 49-year-old man with a history of renal transplantation who presented with low back pain and was diagnosed with epidural and paraspinal abscesses due to Nocardia cyriacigeorgica that was successfully treated with antimicrobial therapy alone. In addition to the case reported here, we also conducted a systematic review of the existing literature regarding spinal abscesses due to Nocardia species and examined the success of the various treatments utilized.

Pediatric cervical epidural abscess in a 4-year-old patient: a case-based update.

PURPOSE: The purpose of this study was to review a case comprised of a cervical spinal epidural abscess, cervical and thoracic paraspinous edema, and widening of the right thoracic neural foramen secondary to a phlegmon. METHODS: We reviewed the case of a spinal epidural abscess managed medically in a 4-year-old male and performed a review of the literature with 15 other cases that have previously been reported. RESULTS: The current mainstay of treatment is largely variant but generally falls into a laminectomy-based surgical approach or longstanding antibiotics. Our review of the literature concluded that there are currently no clear guidelines established to recommend treatment, and current practice is largely based on the discretion of the pediatric neurosurgeon. CONCLUSIONS: Based on the literature review, and our personal case illustration, we conclude that an antibiotic-based treatment is a valid approach for therapy if initiated promptly in a pediatric patient with no neurological deficit.

Upper Cervical Epidural Abscess Resulting in Respiratory Compromise After Lumbar Steroid Injection.

BACKGROUND: Spinal epidural abscesses have a prevalence of 3 out of every 10,000 admissions. Abscesses above the level of C2, defined as upper cervical epidural abscesses, are even rarer still. CASE REPORT: We discuss a case in which a 45-year-old male patient developed an upper cervical epidural abscess 48 h after receiving a lumbar steroid injection. The patient presented with diminished strength in all four extremities and respiratory distress secondary to the space-occupying lesion near his spinal cord. His hospital course included surgical decompression and antibiotics. He was eventually discharged to rehabilitation, but never regained full strength in his arms or legs. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients who present with back or neck pain, fever, and neurologic deficits may have epidural abscess. In some patients, neurologic deficits may include respiratory distress if the upper cervical region is involved, and these patients have the possibility of airway decompensation. The diagnostic imaging modality of choice in patients with epidural abscess is MRI with gadolinium. Management involves supportive care, broad-spectrum antibiotics, which include coverage for methicillin-resistant Staphylococcus aureus, and early neurosurgical consultation.

Epidural abscess caused by Schizophyllum commune: A rare case of rhinogenic cranial complication by a filamentous basidiomycete.

Central nervous system (CNS) infections due to filamentous basidiomycetes are extremely rare. We encountered a case of epidural abscess due to Schizophyllum commune that extended from sinusitis. A 53-year-old Japanese man presented at our hospital with a headache. Computed tomography (CT) of the cranium and sinuses showed ethmoid and sphenoid sinusitis with no intracranial abnormalities. The patient was diagnosed with acute sinusitis and underwent antibiotic treatment. However, the symptoms deteriorated, and the patient came to our hospital again with consciousness disturbance. CT scan of the cranium and sinuses showed no improvement of sinusitis after antibiotic therapy and an epidural abscess emerged in the middle cranial fossa. Therefore, emergency craniotomy and endoscopic sinus fenestration were performed. Filamentous fungal elements were observed in both rhinorrhoea and epidural abscess. The symptoms improved after the operation and administration of liposomal amphotericin B. The clinical isolate was identified as S. commune by a molecular-based method. To our knowledge, this is the first report of epidural abscess due to this fungus. Although rare, clinicians should be aware that S. commune could be a causative agent of CNS infections.

Quadriplegia caused by an epidural abscess occurring at the same level of cervical destructive spondyloarthropathy: a case report.

BACKGROUND: Destructive spondyloarthropathy (DSA) is one of the major complications in patients undergoing long-term hemodialysis. To the best of our knowledge, an epidural abscess occurring at the level of preexisting cervical DSA has not been well described in the literature. We report a unique case of quadriplegia caused by an epidural abscess occurring at the same level of preexisting cervical DSA. CASE PRESENTATION: A 49-year-old woman was transferred to our emergency department with 5 days of sepsis, drowsy mental status, and quadriplegia below the C5 level. The patient had a medical history of hemodialysis for 10 years. Magnetic resonance imaging showed spinal cord compression by an epidural abscess at the level of preexisting cervical DSA. Blood culture revealed methicillin-sensitive Staphylococcus aureus. Infection of the arteriovenous (AV) shunt was considered as the primary focus of sepsis and pyogenic spondylitis. We performed an emergent open door laminoplasty and the vascular team debrided the infected AV shunt site. Approximately 8 months after surgery, the patient was able to perform activities of daily living somewhat independently. CONCLUSIONS: Emergent surgical decompression and intensive medical care led to successful recovery from a septic and quadriplegic state in this patient. When diagnosing a patient who has undergone long-term hemodialysis presenting with neurologic deficits, the possibility of infectious spondylitis at the same level as DSA should be considered.

Lemierre Disease: A Case With Multilevel Epidural Abscess and Aggressive Neurological Weakness: Case Report and Literature Review.

BACKGROUND: Lemierre disease is a rare postanginal sepsis caused by the anaerobe Fusobacterium necrophorum. It is associated with a pharyngitis that progresses quickly to thrombophlebitis of the internal jugular vein and metastatic abscesses to pulmonary, soft tissue, articular, and organ systems. It is rarely associated with spinal epidural abscesses. Because of the increasing antibiotic resistance, its incidence is on the rise. METHODS: A single-patient case report of an adolescent male who initially presented to our institution for bacteremia and febrile episodes. Over a 1-week course, he developed severe back pain and progressive lower extremity weakness. Advanced imaging revealed an epidural abscess spanning T2-L3 level with extension into the psoas and the paraspinal musculature. Acute management consisted of broad-spectrum intravenous (IV) antibiotics and hemilaminectomy decompression from T2 to L3. The patient completed a 6-week course of IV antibiotics and was followed for a 1-year time period with close clinical follow-up. RESULTS: Blood cultures identified the infecting organism as F. necrophorum. The combination of IV antibiotics and acute hemilaminectomy decompression resulted in successful clearance of the infecting organism with normalization of inflammatory markers and cultures. The patient noted immediate and sustained neurological improvement, with return of full motor and sensory function. At the 1-year timepoint, the patient was able to return to sports and no sagittal/coronal imbalance was noted on radiographs. CONCLUSIONS: An aggressive case of Lemierre disease with extensive epidural abscess formation and neurological weakness was successfully managed with the combination of IV antibiotics and extensive hemilaminectomies for decompression. The patient exhibited no long-term sequela as a result of either the epidural abscess or of its treatment. LEVEL OF EVIDENCE: Level V.

A 66-year-old man with neck pain.

Neck pain is a fairly common complaint among patients in the ED. The differential diagnosis is broad, from musculoskeletal causes to potentially life-threatening causes. Providers need to have a good understanding of when the complaint of neck pain requires more diagnostic investigation, even in a patient with chronic neck pain.