Tag Archives: neuro

Vertebral Osteomyelitis/Discitis

23 Dec

submitted by Amit Kumar, M.D.

QUICK HITS:

3 main mechanisms of infection:

  • Hematogenous spread
  • direct inoculation (trauma, spinal surgeries/procedures)
  • contiguous spread from adjacent tissues

 

Culprit:

  • Staph aureus (>50%)
  • enteric gram-neg bacilli (following GU procedures)
  • psuedomonas/candida (often due to IV sepsis or IVDU)
  • group B strep (esp. in diabetics)

Signs & symptoms:

  • Localized spinal pain
  • leukocytosis
  • elevated ESR/CRP
  • fever
  • new radicular symptoms

Diagnostic strategies: Blood culture, MRI (most sensitive radiologic technique), biopsy (open/CT guided)

Differentials: Spinal epidural abscess, psoas abscess, herniated disc, spinal metastasis, vertebral compression fracture

Treatment: Pain control, ANTIBIOTICS (empiric followed by pathogen-directed. Routinely for minimum of 6 weeks), surgery (indications: neuro deficits, abscess needing drainage, cord compression)

Complications:

  • Posterior extension leading to epidural/subdural abscess or meningitis.
  • Anterolateral extension leading to paravertebral/psoas abscess.

***Picture: High signal is T2-weighted MRI at the disc and adjacent vertebral body compatible with diagnosis

Sources:

http://www.uptodate.com/contents/vertebral-osteomyelitis-and-discitis-in-adults?source=search_result&search=discitis&selectedTitle=1~51

http://www.med.harvard.edu/jpnm/tf03_04/jan6/writeup.html

-Picture:http://www.med.harvard.edu/jpnm/tf03_04/jan6/MRI.gif

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concussion precautions: what do you tell your patients?

6 Oct

QUICK PEARLS:

Some rapid-fire pearls to help you discuss the next steps with your concussion patients:

 

On the day of:

NO RETURN TO PLAY (or activities with the potential for contact/re-injury)

 

Next few days: 

  • limit activity and cognitive load (e.g. no video games, limit workload for students, etc)
  • limit meds (acetaminophen is ok), if possible

 

Overall graduated return to protocol recommendations (usually 24-hrs between stages):

Stages:

  1. no activity
  2. light exercise (<70% maximal HR)
  3. sport-specific exercise (e.g. running/skating)
  4. non-contact training (e.g. passing drills)
  5. full-contact practice
  6. return to play

 

What it means:

  1. recovery time
  2. increasing HR
  3. adding movement
  4. coordination & cognitive load
  5. restore confidence and assess functional skills
  6. normal game play

 

If symptomatic at any stage, go back to the previous level, then try again in 24 hrs. 

 

References: emdocs article; Mccrory P, et al. “Consensus Statement on Concussion in Sport—the 4th International Conference on Concussion in Sport Held in Zurich, November 2012.” Clinical Journal of Sport Medicine 23.2 (2013): 89-117.; NATA position statement; picture

blood pressure targets (strokes, bleeds, and tears)

15 Sep

 

Adapted from an old post, but a good refresher that came up again recently, with a new little table from a recent emed journal article that includes some recommendations for BP targets in stroke (ischemic or otherwise):

neuroBP

 

(and from a previous post):

IS SOMETHING BLEEDING (OR ABOUT TO)?  MINIMIZE THE DAMAGE:

ICH:

–lowering to SBP 140-160 probably safe

–theory: less/slower hematoma growth

–options: nicardipine (less cerebral vasospasm)

 

AORTIC DISSECTION:

SBP 100-120, HR <60

–theory: reduce shear forces

–options: beta blocker (labetolol push, esmolol drip), nitroprusside

 

RUPTURED AAA:

–goal SBP 80-100

–theory: permissive hypotension; bleed slower, less likely to blow out the few clots they’re making

Reference(s): emed-journal articleuptodate.com: Ruptured abdominal aortic aneurysm, management of aortic dissection, Spontaneous intracerebral hemorrhage: Prognosis and treatment, Kodama K, et al. Tight heart rate control reduces secondary adverse events in patients with type B acute aortic dissection, picture

deep tendon reflexes: which test for which nerve root?

11 Aug

Some quick reminders and visual aids on which reflexes test which nerve roots:

C5 – Biceps

C6 – Biceps, Brachioradialis

C7 – Triceps

L4 – Patellar (knee jerk)

S1 – Achilles (ankle jerk)

 

This NYU site has some good pictures for each tendon reflex, but here’s a quick & dirty picture for those short on time:

reflexes

 

There you go.  Add it to the mental rolodex.

 

References: neuroexam.com, NYU neuro exam site, picture

strength in numbers: subarachnoid hemorrhage

30 Jul

via a recent EP monthly article on acute SAH vs. traumatic tap:

 

sensitivity of CT for diagnosing aSAH: 93% (95% CI 89-96%)

sensitivity of CT  within 6 hrs of headache onset: 100% (95% CI 97-100%)

sensitivity of CT beyond 6 hrs: 86% (95% CI 78-91%)

 

traumatic taps in up to 30% of LPs

 

one study (caveats: required dx of aneurysmal aSAH on CTA, and 8/15 SAH dx by LP were missed on initial CT read):

  • cutoff of <2000 x 10^6/L  CSF RBCs: 93% sensitivity (CI 66-99.7%)
  • cutoff of <2000… RBCs + no xanthochromia: 100% sensitivity (CI 74.7-100%)
  • only 15 cases of aSAH diagnosed by LP at 12 academic centers in 10 years
  • interesting, but not practice changing just yet

 

Food for thought.

 

References: epmonthly article, picture

strength in numbers: dizziness

23 Apr

Cribbed from this March ACEP Now article:

 

DIZZINESS/VERTIGO: numbers to consider

clinical factors associated with stroke in vertiginous patients

  • gait instability: Odds Ratio (OR) 9.3
  • subtle neurological findings: OR 8.7

 

predictors for serious neurological disease with complaint of dizziness, vertigo, or imbalance

  • Focal neurological abnormalities: OR 5.9
  • 60 years of age or older: OR 5.7
  • Imbalance: OR 5.9
  • Isolated dizziness: OR 0.20  (i.e. 80% less likely to be experiencing a serious neurological cause)

 

Study of 1681 pts w/dizziness:

  • CTs obtained in 48%
  • MRI’s in 5%

 

  • cost associated with identifying one abnormal CT: $165k
  • cost associated with identifying one abnormal MRI: $22k
  • all patients with positive CT or MRI had headache, neuro findings on exam, or optho complaints

 

5-SECOND TAKEAWAY:

  • don’t skimp on the neuro exam
  • walk (gait test) your dizzy patients

 

References: ACEP Now Article; picture

strength in numbers: meningitis

7 Apr

just to keep you honest (highlights via this EMdocs article)

“classic triad” (fever, altered mental status, stiff neck)

  • 95% had fever,
  • 88% had neck stiffness,
  • 78% had altered mental status.
  • only 44% of patients with meningitis had all three 

 

Neck pain: 28% sensitivity

headache: 50% sensitivity

 

avoid minimizing afebrile patients, especially in the elderly population: as many as 18% of these patients with meningeal infection may be afebrile

Kernig and Brudzinski signs

  • 95% specificity
  • sensitivity is as low as 5%.

 

“jolt test” (headache accentuated by horizontal rotation of the head at a frequency of two to three times per second)

  •  sensitivities ranging from 97% to 21%

 

opening pressure: as many as 9% are less than 14 cm/H20

 

their conclusion: “Ultimately, outside of a positive CSF culture, no one test or exam should rule in or out the diagnosis of meningitis
References: emdocs article; picture