AC152

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Question

AC152 [Apr07] [Jul07]

Regarding Epidural Abcess - which is WRONG
A. Diagnosis is DEPENDENT on triad of back pain, fever, and paralysis
B. Occurs at a rate of 1:1000-3000 (OR 1:2000 - 1:5000)
C. Worse outcomes if advanced age
D. Usually gram positive cocci
E. Expectant management may be appropriate

(Similar MCQs: AC145, AC109)

Worked Answer

AC152 [Apr07] [Jul07]

Regarding Epidural Abcess - which is WRONG

  • A. Diagnosis is DEPENDENT on triad of back pain, fever, and paralysis - false and the ANSWER to CHOOSE: "The early signs and symptoms may be vague, the 'classic' triad of back pain, fever and variable neurological deficit occurred in only 13% of patients by the time of diagnosis, and contributed to diagnostic delay in 75%." (Grewal et al, Epidural Abscesses in BJA 2006 96(3):292-302)
  • B. Occurs at a rate of 1:1000-3000 (OR 1:2000 - 1:5000) - true: "Estimating the true incidence of a rare complication from such disparate reports is not easy, but there is some suggestion that it might be of the order of 1 in 1000 in surgical, and 1 in 2000 in obstetric, patients." (Grewal et al, Epidural Abscesses in BJA 2006 96(3):292-302)
  • C. Worse outcomes if advanced age - true: "With every decade increase in age, the likelihood of poor outcome doubled, presumably due to declining health and, possibly, reduced ‘plasticity’ of the spinal cord." (Grewal et al, Epidural Abscesses in BJA 2006 96(3):292-302)
  • D. Usually gram positive cocci - true: "In the ‘developed’ world the organisms most frequently encountered are Staphylococcus aureus (57–93% of cases), Streptococci (18%) and a variety of Gram-negative bacilli (13%)." (Grewal et al, Epidural Abscesses in BJA 2006 96(3):292-302)
  • E. Expectant management may be appropriate - true: "It might be assumed that every patient with an epidural abscess should undergo surgery, but 11% of those identified in a major review did not, and another report identified 38 such individuals in case series and reports published between 1970 and 1990... The neurological deficit was unchanged or improved in all these patients except two, who died from sepsis syndrome, suggesting that the results of medical and surgical treatment are equivalent." (Grewal et al, Epidural Abscesses in BJA 2006 96(3):292-302)

Comments

From reference below, A is wrong. This triad occurs in only 13% of patients with abcesses. Morbidity doubles with every decade and 75% are due to G+ve cocci. B is rather dubious but quoted in the article. Drstapes

The choice B definitely said incidence of 1:1000-1:5000 in our paper (Jul07). Because I've been tossing between A and B for a longtime.--Life is Beautiful 03:45, 31 Jul 2007 (EDT) The answer is A. Fever may be the only presenting sign. Paralysis can be a late sign and is not necessary for diagnosis. Ref BJA review on epidural abscesses, June 2006.--Spinner of plates 06:15, 2 Aug 2007 (EDT)

Surely E is wrong too: non surgical management may be appropriate in some cases (as per the BJA review) but this is not the same as "expectant managment" piper

I know the college quotes rates of 0.015-0.05% (1:2000-66 000) but this article "Incidence of Epidural Hematoma, Infection, and Neurologic Injury in Obstetric Patients with Epidural Analgesia/Anesthesia" [1][Anesthesiology 2006; 105:394–9] (only obstetric epidurals I know) quotes much lower rates at about 1:145 000. There's such a range of numbers in the literature but 1:1000-5000 seems too low to me. Having said all that, I reckon they're after A as the "lesson to be learned" here. --Tortis 20:34, 30 Jan 2009 (EST)

depends on whether it is sponatneous or after epidural catheter : sponatneous 1:5000 to 1:10000 and epidural catheter related is 1: 110000 to 1:145000-gb. want to contradict myself because bible says 1:5000. (1:2000 to 1:7500)

minkel777 - i'm voting A. I think this question came from the BJA article epidural abscesses as mentioned

References

  • Epidural Abscesses BJA 2006(3):292-302
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