A 54-year-old man with a history of diverticulitis complicated by intra-abdominal abscess status postbowel resection presented with nuchal rigidity, proximal weakness from upper extremities to lower extremities, and associated numbness shortly after surgery. Admission LP revealed a leuko-pleocytosis (146 cells/mul) with 93% lymphocytes and elevated protein (162 mg/dL). Antibiotics were initiated with a repeated tap performed 4 days after initial LP. Concern for autoimmune disorder grew when antibiotic coverage failed to resolve the patient's bilateral inflammatory cervical polyradiculopathies. A course of intravenous immunoglobulin was administered with marginal improvement of his weakness. Repeat tap performed under fluoroscopic guidance 11 days postinitial LP demonstrated resolution of the leukocytosis; however, the tap was notably traumatic with red blood cells (RBCs) above 31,000/mul.
On postadmission day 19 and 8 days status post-LP under fluoroscopy, the patient reported severe lower back pain, worsening lower extremity weakness, saddle anesthesia, and urinary retention. Magnetic resonance imaging (MRI) of the lumbar spine with and without gadolinium contrast demonstrated an intrathecal subarachnoid and subdural hematoma extending from L3 through the sacral levels [Figure 1].
Urgent neurosurgery consultation resulted in decompressive surgery within 24-h of symptom onset. Laminectomies were performed between inferior L2 and L5, at which time a small ventrolateral epidural hematoma was identified compressing the spinal cord at the L4 level. Initially, the thecal sac appeared tightly stretched and bluish discolored from intradural hemorrhage; however, removal of the epidural hematoma and maneuvers to mobilize the dura and spinal cord dislodged the intradural collection as evidenced by adequate ventilation-synchronous respiratory pulsations of the CSF with each breath, as well as a slack and tension-free thecal sac. As a result, the dura was not opened for clot evacuation since decompression (the goal of surgery) had been achieved without perioperative complication.
Postoperatively, the patients' urinary retention resolved and the patient began ambulating with wide-based stable gait. Follow-up appointments at 6 and 12 months revealed significant improvements in strength with near resolution of all proximal weakness and only residual dyspnea secondary to underlying pulmonary disease. No bowel/bladder dysfunction, lower extremity weakness, or anesthesia was present.