WBR259

Author	Mahmoud Sakr M.D.
Exam Type	USMLE Step 3
Main Category	Inpatient Facilities
Sub Category	Infectious Disease, Neurology
Prompt	89 y/o Caucasian male is admitted to the hospital due to altered mental status, lower back pain and development of a low-grade fever. His past medical history is remarkable for hypertension, hyperlipidemia, prior MI, prostate cancer and advanced dementia. Temperature is 99.6, Blood pressure is 109/67, Pulse is 95, Respiratory rate is 20. Physical exam is notable for absence of spontaneous movement of his lower extremities and loss of sensation from his waist downwards. He’s also unable to control neither his bladder nor his bowels. What is the most important next step in management?
Answer A	Order an urgent MRI of the spine
Answer A Explanation	This is an important diagnostic step and can be done, but after the surgical team is informed.
Answer B	Start broad spectrum IV antibiotics
Answer B Explanation	This answer is important and should be done after blood cultures are taken
Answer C	Neurosurgical consultation. This patient is having cauda equina signs and immediate surgical consultation and operative decompression is the first step in management. All other answers are appropriate in the meantime, but after steps towards surgical release are taken.
Answer C Explanation	Correct.
Answer D	Start IV dexamethasone
Answer D Explanation	IV steroids are used in clinical practice by neurosurgeons and often administered empirically if cauda equina is suspected, however this is not the first step in management.
Answer E	Obtain 2 sets of blood cultures.
Answer E Explanation	This step would be next after neurosurgical consult.
Right Answer	C
Explanation	A spinal epidural abscess threatens the spinal cord or cauda equina by compression and also by vascular compromise (see images below). If untreated, an expanding suppurative infection in the spinal epidural space impinges on the spinal cord, producing sensory symptoms and signs, motor dysfunction, and, ultimately, paralysis and death. This patient is having cauda equina signs and immediate surgical consultation and operative decompression is the first step in management. All other answers are appropriate in the meantime, but after steps towards surgical release are taken. Educational Objective: References:
Approved	Yes
Keyword
Linked Question
Order in Linked Questions