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A 20 year old woman attended the accident and emergency department complaining of right sided neck pain three days after extraction of a wisdom tooth under general anaesthetic. The physical examination was consistent with a musculoskeletal neck sprain resulting from posture during the extraction and the patient was discharged with a soft cervical collar, non-steroidal analgesia and referred to physiotherapy. She returned three days later (six days after the original procedure) complaining of increased right sided neck pain and a sensation of numbness to the right arm. On examination she was found to have no neurological deficit but was found to be very tender over the C5 spinous process and marked tenderness was found on the right side of the neck. A radiograph was normal and further analgesia was prescribed.
The patient was referred to the on call orthopaedic team by the general practitioner three days later (nine days after the original presentation) with severe neck pain and having developed a paresis in her right arm and right leg. Later that day she developed a right sided paralysis in addition to a left sided paresis. The patient was sent for computed tomography and subsequent magnetic resonance imaging (MRI), which revealed an epidural abscess to the right side of C4/C5 vertebrae with an abnormal signal from within the cord at this level. This was also found to communicate with a large pre-vertebral collection (see fig 1). She was then urgently given intravenous antibiotics and referred to the on call neurosurgical team for drainage of the abscess and cord decompression. A total recovery resulted to the left arm and left leg. However, paralysis persisted to the right arm and right leg.
This case report is only the second recorded episode of an epidural abscess resulting from a dental extraction.1 The diagnosis of an epidural abscess was made by MRI, which is currently regarded as gold standard.2 The abscess is mainly caused by local and haematogenous spread. Blood cultures showed the presence of Streptococcus milleri, which is a known mouth commensal and an uncommon cause of epidural abscess. Culture of the abscess after surgical decompression revealed Corynebacteria, which are non-specific for an oral cause. The difficulty with the differential diagnosis of acute torticollis has been previously eluded to3 and the vital importance of early diagnosis leading to early treatment is well documented.4 It also exemplifies a serious underlying disorder with an apparent innocuous cause.
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