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A 53-year-old male with a history of coronary artery disease presents with progressively worsening back pain associated with fevers and chills. On physical examination, there are no sensory or motor changes with stable vital signs. Labs are significant for C-reactive protein of 80 mg/L, ESR of 72 mm/hr, white blood cell count of 11500 cells/mL, and blood cultures positive for methicillin-susceptible Staphylococcus aureus (MSSA). Figures A and B are the current MRI images. Which of the following is the most appropriate treatment for this patient?
Discharge home with oral linezolid for 6 weeks
Admission and bracing with IV cefazolin for 6 weeks
Lumbar laminectomy, followed by IV vancomycin for 6 weeks
Anterior lumbar interbody fusion, followed by IV vancomycin for 6 weeks
Lumber laminectomy with instrumented fusion, followed by IV vancomycin for 6 weeks
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An MRI is shown in Figure 1. Which of the following patients with the MRI findings shown would be most likely to require surgical management?
24-year-old female, neurologically intact, WBC 10k, CRP 20.0mg/dL, MRSA-positive blood culture
47-year old diabetic male, severe midline lower back pain, WBC 14k, CRP 8.0mg/dL, negative blood cultures
55-year-old male, stable bilateral thigh paresthesias, WBC 20k, CRP 15mg/dL, negative blood cultures
67-year-old diabetic female, mild bilateral leg weakness, WBC 12k, CRP 9.0mg/d, MRSA-positive blood culture
75-year-old diabetic male, neurologically intact, WBC 11k, CRP 10.0mg/d, MRSA-positive blood culture
A 56-year-old female with a history of diabetes and urosepsis 2 months ago presents with worsening lower back pain. The patient denies any fevers at home. She presented to an ED several weeks ago with similar complaints where radiographs of the lumbar spine were normal. Physical exam demonstrates 3/5 motor strength in the iliopsoas, quadriceps, and triceps surae muscles. Ankle dorsiflexion causes sustained clonus. An MRI is performed and shown in figure A. What is the next best step in treatment?
Broad spectrum antibiotics
CT guided aspiration of the L2-3 disc space
L2-3 disc space debridement and anterior interbody fusion
Antibiotics and L4-5 laminectomy and instrumented posterior spinal fusion
MRI imaging of the entire spine
A 42-year-old intravenous drug abuser presents with a 1 month history of fevers, chills, and worsening gait instability. Physical exam reveals weakness in the bilateral upper and lower extremities. Her sagittal MRI is depicted in Figure A. Figure B is her axial MRI at the C4-C5 level. What is the most appropriate next step in management?
Cervical collar with IV methylprednisone
Broad spectrum IV antibiotics
Anterior decompression and fusion
IR-guided biopsy and culture
Posterior laminectomy and fusion
A 47-year-old female presents to the emergency room with 6 weeks of back pain. She underwent aortic valve replacement for acute endocarditis 8 weeks ago. On physical examination, she has progressive bilateral lower extremity weakness and diminished sensation to light touch. Her right ankle demonstrates 8 beats of clonus. Her labs are significant for a white blood cell count of 15,800 as well as an elevated ESR and CRP. Which of the following imaging studies is most consistent with the patient’s clinical presentation?
A 40-year-old woman with history of intravenous drug abuse and ongoing Staphylococcus aureus septicemia is referred for intractable neck pain with radiation down her arm. She also complains of progressive hand weakness. Examination reveals long tract signs in the lower extremities. Her MRI scan is shown in Figure A. Besides intravenous antibiotics, what is the most appropriate next step in treatment?
Percutaneous CT guided aspiration, hard cervical orthosis until bony union.
Percutaneous CT guided aspiration, hard cervical orthosis, repeat aspiration at 6-12 weeks followed by anterior corpectomy and fusion if repeat aspiration is sterile.
Anterior cervical debridement and anterior corpectomy without instrumentation
Posterior cervical debridement and instrumented posterior fusion.
Anterior cervical debridement, corpectomy and fusion followed by a posterior instrumented stabilization procedure
A 31-year-old female from the United States who is an active IV drug abuser presents with worsening gait instability for the last four days. She has no history of prior international travel. Physical exam shows diffuse weakness in her upper and lower extremities. A sagittal MRI is shown in Figure A. What is the next most appropriate step in management?
Anterior decompression and fusion
Posterior decompression and fusion
Methylprednisone loaded at 30 mg/kg followed by drip at 5.4 mg/kg/hr drip for 23 hrs
Broad spectrum IV antibiotics and bracing
CT guided biopsy
A 64-year-old female accountant from Oregon is diagnosed with endocarditis 6 months ago underwent a course of IV antibiotic treatment. She now reports 3 months of severe low back pain and progressive lower extremity weakness and paresthesias for the past week. Her leukocyte count is normal and she is afebrile. The ESR and CRP are elevated. Radiographs and MRI scans are shown in Figures A and B, respectively. What is the most appropriate next step in management?
Intrathecal catheter placement with antibiotic administration for 6 weeks
Irrigation and debridement, corpectomy, and fusion
Oral prednisone regimen for 4 weeks
Irrigation and debridement via posterior approach
Initiation of multiagent antibiotic regimen for tuberculosis for 6 months