WBR1505

Author	PageAuthor::William J Gibson
Exam Type	ExamType::USMLE Step 2 CK
Main Category	MainCategory::Internal medicine
Sub Category	SubCategory::Neurology, SubCategory::Neurology
Prompt	[[Prompt::A 58 year old woman presents to the hospital for bilateral lower extremity leg cramps, paresthesias, and lower extremity weakness (right greater than left). She reports the symptoms occurred gradually over the course of two days. On admission, she is found to have urinary retention and a foley catheter is inserted. On physical exam she is afebrile, and her mental status is normal. She has symmetric 2+ reflexes in the lower extremities. Proprioception and sensation to vibration are diminished bilaterally in the lower extremities. The patient reports a general feeling of numbness below the umbilicus. She is unable to stand or ambulate on her own. The results of T2 spinal MRI are shown below. A lumbar puncture is performed, which demonstrates total protein of 141 mg/dL, glucose of 80 mg/dL and 13 WBC/mL. What is the most likely diagnosis?]]
Answer A	AnswerA::Central cord syndrome
Answer A Explanation	[[AnswerAExp::Central cord syndrome is defined as injury to the central portion of the spinal cord. It is typically caused by hyperextension injuries in the cervical spine (eg whiplash). It typically causes weakness in a cape-like distribution along the upper extremities.]]
Answer B	AnswerB::Transverse myelitis
Answer B Explanation	AnswerBExp::
Answer C	AnswerC::Tabes dorsalis
Answer C Explanation	AnswerCExp::
Answer D	AnswerD::Anterior cord syndrome
Answer D Explanation	[[AnswerDExp::Anterior cord syndrome is caused by injury to the anterior part of the spinal cord. These lesions typically affect the corticospinal tract and the spinothalamic tract. Therefore, patients frequently have paralysis and loss of pain/temperature below the level of the lesion. Because proprioception and vibration travel in the posterior aspect of the spinal cord, they are unaffected.]]
Answer E	AnswerE::Cauda equina syndrome
Answer E Explanation	[[AnswerEExp::Cauda equina syndrome is caused by the compression of the nerve roots that leave the lumbosacral spinal cord in the cauda equina. These patients typically have saddle anesthesia, bowel/bladder dysfunction and sciatica-like pain. The imaging in this patient demonstrates a lesion in the thoracic vertebrae. The lumbosacral spine is not pictured.]]
Right Answer	RightAnswer::B
Explanation	[[Explanation::The patient in this vignette has transverse myelitis. She has symptoms of an upper motor neuron lesion (hyperreflexia) in both lower extremities. Her CNS insult is therefore either in the spine or the brain. Educational Objective: References: ]]
Approved	Approved::No
Keyword	WBRKeyword::Neurology, WBRKeyword::Demyelination, WBRKeyword::Demyelinating, WBRKeyword::Transverse myelitis, WBRKeyword::Myelopathy, WBRKeyword::MGHRDA, WBRKeyword::Paralysis, WBRKeyword::Spine, WBRKeyword::RDA
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::