Acute Cauda Equina Syndrome Caused by Epidural Steroid Injection in the Setting of a Spinal Dural Arteriovenous Fistula.

We present a case of acute cauda equina syndrome caused by an epidural steroid injection in the setting of a previously undiagnosed spinal dural arteriovenous fistula (SDAVF). Our patient was a 61-year-old man who presented to the emergency department with low back pain, inability to walk, paresthesias of his bilateral lower extremities, bowel and bladder incontinence, and saddle anesthesia. Physical examination revealed weakness and decreased sensation of the lower extremities as well as poor rectal tone and urinary retention. Magnetic resonance imaging (MRI) revealed evidence of spinal cord edema in the T9-10 region and a probable SDAVF with secondary distal thoracic cord ischemia. This case highlights the importance of prompt recognition of cauda equina syndrome in the emergency department, expedient imaging, and efficient transfers of care, which allowed this patient to quickly undergo necessary surgery that led to an almost complete recovery. It also highlights the importance of recognizing subtle changes on lumbar MRI.

Anemia in the emergency department: evaluation and treatment.

Anemia is a common worldwide problem that is associated with nonspecific complaints. The initial focus for the emergency evaluation of anemia is to determine whether the problem is acute or chronic. Acute anemia is most commonly associated with blood loss, and the patient is usually symptomatic. Chronic anemia is usually well tolerated and is often discovered coincidentally. Once diagnosed, the etiology of anemia can often be determined by applying a systematic approach to its evaluation. The severity of the anemia impacts clinical outcomes, particularly in critically ill patients; however, the specific threshold to transfuse is uncertain. Evaluation of the current literature and clinical guidelines does not settle this controversy, but it does help clarify that a restrictive transfusion strategy (ie, for patients with a hemoglobin < 6-8 g/dL) is associated with better outcomes than a more liberal transfusion strategy. Certain anemias may have well-defined treatment options (eg, sickle cell disease), but empiric use of nutritional supplements to treat anemia of uncertain etiology is discouraged.