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

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 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.

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