A 64-year-old man is brought to the emergency department due to sudden onset of painless lower extremity weakness. He was swimming in a pool when he suddenly felt his legs become weak and had to struggle to exit the pool. The patient has had no loss of consciousness or visual or speech problems, but he is unable to pass urine. He also has had back pain for the last 2 months. Medical history is significant for type 2 diabetes mellitus, hypertension, and osteoarthritis. Physical examination shows significant motor weakness in both legs and numbness from the umbilicus to the soles of the feet. He has no sensation in the perineal area. Rectal tone is absent. A urinary catheter is placed, and 800 mL of urine is collected. Which of the following is the best next step in management of this patient?

Question

A 64-year-old man is brought to the emergency department due to sudden onset of painless lower extremity weakness.  He was swimming in a pool when he suddenly felt his legs become weak and had to struggle to exit the pool.  The patient has had no loss of consciousness or visual or speech problems, but he is unable to pass urine.  He also has had back pain for the last 2 months.  Medical history is significant for type 2 diabetes mellitus, hypertension, and osteoarthritis.  Physical examination shows significant motor weakness in both legs and numbness from the umbilicus to the soles of the feet.  He has no sensation in the perineal area.  Rectal tone is absent.  A urinary catheter is placed, and 800 mL of urine is collected.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d540_bfe2_bc81_0be318ee9ba1_MD0003_00 This patient's presentation-motor and sensory loss below a defined spinal level, absent rectal tone, and urinary retention-is worrisome for acute spinal cord compression (SCC). SCC is most commonly caused by malignancy, disk herniation, trauma, or epidural abscess. Patients typically develop lower extremity weakness with loss of rectal tone (descending corticospinal tract involvement), sensory deficit that is typically ≥2 spinal cord segments below the level of the lesion (ascending spinothalamic tract involvement). Urinary retention occurs with a lesion above the S2 level (autonomic descending motor tract involvement). Symptoms may be progressive (eg, with enlarging epidural abscess) or present more acutely (eg, with fracture). Activity, such as swimming in this patient, may herald the onset of symptoms in those with unstable spinal columns (eg, due to vertebral metastases). A history of progressive back pain is common (particularly with malignancy) and often precedes neurologic manifestations by 6-8 weeks. Immediate neurosurgical evaluation is warranted to avoid permanent neurologic dysfunction. Neuroimaging (ie, MRI of the spine) is performed while awaiting surgical consultation. High-dose glucocorticoids are often used, especially in cases of suspected malignant compression. (Choice A) Emergency noncontrast CT of the head is indicated for the evaluation of acute stroke or suspected intracranial hemorrhage. This patient's bilateral lower extremity, bowel, and bladder findings localize the disorder to the spinal cord. (Choice B) Lumbar puncture is indicated to evaluate for meningitis, which causes neck pain, fevers, and headache, not lower weakness/sensory loss or urinary retention. (Choice C) Nerve conduction studies are used for diagnosis of peripheral neurologic disorders, especially to differentiate between diseases affecting the neuromuscular junction, muscle, and nerve. They are not advised in the initial evaluation of patients with spinal cord injury. (Choice D) Thoracolumbar bracing is sometimes used for patients with spinal stenosis without progressive neurological deficits. This patient has neurologic deficits consistent with acute SCC, and urgent intervention is necessary to minimize the possibility of permanent disability. Educational objective: Acute spinal cord compression can present with loss of motor and sensory function, loss of rectal tone, and urinary retention. Management includes emergency surgical consultation, neuroimaging, and possibly intravenous glucocorticoids. References: Emergency neurological life support: spinal cord compression (SCC). (http://www.ncbi.nlm.nih.gov/pubmed/22956117)

A 64-Year-Old Man Is Brought to the Emergency Department Due