Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: 38-year-old man with bilateral lower extremity paralysis

mksap
Conditions
August 4, 2012
Share
Tweet
Share

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 38-year-old man is admitted to the hospital for a 12-hour history of bilateral lower-extremity paralysis. The patient is an injection drug user. Over the past week, he developed lower back pain, which progressed to pain and numbness radiating down both lower extremities. On the day of admission, he was unable to walk but continued to use injection drugs.

On physical examination, vital signs, including temperature, are normal. Cardiac examination reveals a regular rhythm and a grade 2/6 holosystolic murmur heard at the apex and radiating to the axilla. Neurologic examination demonstrates 0/5 strength in both lower extremities and absent sensation in both legs.

Emergent MRI of the spine shows evidence of osteomyelitis of the L1 and L2 vertebrae, diskitis of the L1-L2 disk space, and an epidural fluid collection compressing the spinal cord. Three blood cultures are drawn, and empiric therapy with vancomycin and ceftazidime is initiated.

In addition to continuing antimicrobial therapy, which of the following is the most appropriate management?

A) CT-guided aspiration of the epidural fluid collection
B) Electromyography of the lower extremities
C) Emergent laminectomy
D) Lumbar puncture

MKSAP Answer and Critique

The correct answer is C) Emergent laminectomy. This item is available to MKSAP 15 subscribers as item 72 in the Infectious Disease section. MKSAP 16 will release Part A on July 31. More information is available online.

This patient has a spinal epidural abscess and vertebral osteomyelitis. Given his history of injection drug use, he likely has infective endocarditis with continuous bacteremia, leading to seeding of his lumbar spine and development of the epidural fluid collection. The likely infecting organisms are Staphylococcus aureus and gram-negative bacilli, and appropriate empiric antimicrobial therapy has been initiated.

Patients with spinal epidural abscess and neurologic dysfunction require urgent laminectomy with decompression and drainage, although surgery is not likely to be a viable therapeutic option in patients who have experienced complete paralysis of longer than 24 to 36 hours’ duration; some experts, however, would perform surgical therapy in patients in whom complete paralysis has lasted fewer than 72 hours. Given that this patient’s symptoms of paralysis lasted only 12 hours prior to presentation, emergent laminectomy is indicated to attempt to reverse the neurologic deficits.

CT-guided aspiration would likely identify the causative microorganism (approximately 90% of cultures are positive) but would be inadequate to treat the neurologic dysfunction. Electromyography would offer no other information and would not further guide the management of this patient.

Lumbar puncture for cerebrospinal fluid examination is not necessary and will not contribute to the management of this patient. Typical findings include an elevated protein level and pleocytosis, and Gram stain and cultures are negative in more than 75% to 80% of patients.

Key Point

  • Emergent laminectomy should be performed in patients with spinal epidural abscess and neurologic dysfunction of less than 24 to 36 hours’ duration.

Learn more about ACP’s MKSAP 16.

This content is excerpted from MKSAP 15 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 15 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

ADVERTISEMENT

Prev

E-cigarettes: Are there better ways to quit smoking?

August 3, 2012 Kevin 2
…
Next

The public needs access to federally funded research

August 4, 2012 Kevin 2
…

Tagged as: Infectious Disease, Neurology

Post navigation

< Previous Post
E-cigarettes: Are there better ways to quit smoking?
Next Post >
The public needs access to federally funded research

ADVERTISEMENT

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

More in Conditions

  • Why medicine must stop worshipping burnout and start valuing humanity

    Sarah White, APRN
  • Why perinatal mental health is the top cause of maternal death in the U.S.

    Sheila Noon
  • A world without vaccines: What history teaches us about public health

    Drew Remignanti, MD, MPH
  • Unraveling the mystery behind one of the most dangerous pregnancy complications: preeclampsia

    Thomas McElrath, MD, PhD and Kara Rood, MD
  • How community paramedicine impacts Indigenous elders

    Noah Weinberg
  • Pain is more than physical: the story your body is trying to tell

    Katie Hatt, DO
  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How community paramedicine impacts Indigenous elders

      Noah Weinberg | Conditions
    • Addressing U.S. vaccine inequities in vulnerable communities [PODCAST]

      The Podcast by KevinMD | Podcast
    • How to speak the language of leadership to improve doctor wellness [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
  • Recent Posts

    • Addressing U.S. vaccine inequities in vulnerable communities [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why Canada is losing its skilled immigrant doctors

      Olumuyiwa Bamgbade, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Would The Pitts’ Dr. Robby Robinavitch welcome a new colleague? Yes. Especially if their initials were AI.

      Gabe Jones, MBA | Tech
    • Why medicine must stop worshipping burnout and start valuing humanity

      Sarah White, APRN | Conditions
    • Why screening for diseases you might have can backfire

      Andy Lazris, MD and Alan Roth, DO | Physician

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

  • Most Popular

  • Past Week

    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • How community paramedicine impacts Indigenous elders

      Noah Weinberg | Conditions
    • Addressing U.S. vaccine inequities in vulnerable communities [PODCAST]

      The Podcast by KevinMD | Podcast
    • How to speak the language of leadership to improve doctor wellness [PODCAST]

      The Podcast by KevinMD | Podcast
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • Why are medical students turning away from primary care? [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why “do no harm” might be harming modern medicine

      Sabooh S. Mubbashar, MD | Physician
    • Here’s what providers really need in a modern EHR

      Laura Kohlhagen, MD, MBA | Tech
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • How medical culture hides burnout in plain sight

      Marco Benítez | Conditions
  • Recent Posts

    • Addressing U.S. vaccine inequities in vulnerable communities [PODCAST]

      The Podcast by KevinMD | Podcast
    • Why Canada is losing its skilled immigrant doctors

      Olumuyiwa Bamgbade, MD | Physician
    • Why doctors are reclaiming control from burnout culture

      Maureen Gibbons, MD | Physician
    • Would The Pitts’ Dr. Robby Robinavitch welcome a new colleague? Yes. Especially if their initials were AI.

      Gabe Jones, MBA | Tech
    • Why medicine must stop worshipping burnout and start valuing humanity

      Sarah White, APRN | Conditions
    • Why screening for diseases you might have can backfire

      Andy Lazris, MD and Alan Roth, DO | Physician

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...