Acute progressive neurological decline in an elderly man

The patient was an 88-year-old man referred to a physical therapist by his primary care physician for a 1-week history of severe neck pain of insidious onset. Based upon the history and physical examination, the physical therapist concluded that the patient's neck pain was mechanical in nature. Initial physical therapist intervention included cervical taping, cervical collar use and instruction in home exercise. At his follow-up visit 4 days after his initial physical therapy visit, the patient reported no improvement. The patient's son, who accompanied him to this visit, also reported that his father had a recent onset of fever and mild confusion. The case was discussed with the patient's physician and it was recommended that the patient report to the emergency department. Evaluation in the emergency department revealed that the patient was febrile with diminished oxygen saturation and an elevated white blood cell count. Chest radiographs were consistent with pneumonia and blood cultures were positive for methicillin-resistant Staphylococcus aureus. The patient was hospitalized and over the next 6 days, his condition progressively declined and quadriplegia below the C4 myotomal level developed. Magnetic resonance imaging of the cervical spine revealed severe cervical central canal stenosis with extensive signal abnormality in the cervical cord, as well as diffuse oedema in the perivertebral soft tissues that was consistent with a retropharyngeal abscess. Despite medical management, the patient subsequently succumbed to the complications of pneumonia and quadriplegia.