Adrenal crisis — MCCQE Part 1 MCQ

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HardWeaknessAdrenal crisisMCCQE Part 1

A 52-year-old with severe low-back pain develops progressive bilateral leg weakness, saddle numbness, and new painless urinary retention. Post-void residual is 650 mL. There is no contraindication to MRI. What is the most appropriate next step?

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Correct answer: E — Obtain urgent MRI and contact spine surgery

Progressive bilateral weakness, saddle sensory loss, and new urinary retention strongly suggest cauda equina compression. This is a time-critical neurologic emergency. Urgent lumbar MRI should be obtained and the on-call spine service contacted in parallel; a bladder catheter can relieve retention but does not treat the compression. If MRI is genuinely unavailable, CT may be used as an interim study while transfer and definitive imaging are arranged. Plain radiographs cannot assess the cauda equina. Analgesia, physiotherapy, or delayed review would risk permanent bladder, bowel, sexual, and lower-limb dysfunction. A lower post-void residual can reduce the likelihood of cauda equina syndrome but does not exclude it when red flags are present; here the residual is markedly elevated.

Reference: Canadian Association of Radiologists, Spine Referral Guideline: https://car.ca/wp-content/uploads/2024/11/CAR_Spine_Referral_Guideline_FINAL.pdf