Dear Bloggers
This anonymised case is a warning for all of you out there when you see someone with leg weakness and numbness to appreciate how rapidly problems can progress. Please try and answer the case as best you can and you are welcome to leave your answers anonymously.
A 70 year old female who was otherwise well was admitted following a short history of
A 70 year old female who was otherwise well was admitted following a short history of
- numbness of the buttocks
- rapid onset lower limb weakness
The patient had got up for breakfast normally and was sitting eating her breakfast. She suddenly began to notice numbness of her buttock region and a 'heavy' feeling in her lower back. She decided to visit the toilet as she thought she might pass stool. In the toilet the sensation continued and after several minutes, the patient was unable to stable from the toilet seat because of leg weakness. Her family were concerned and called an ambulance and the patient was taken to the local hospital.
The patient denied any back pain. There was no history of vertebral disc problems, no chest pain or abdominal pain. There were no palpitations. The patient denied symptoms of diabetes such as excessive thirst, blurred vision etc. There was no history of being previously unwell and there were no symptoms consistent with infection or bleeding.
The patient was a known hypertensive and took atenolol 25mg once daily.
She had no drug allergies. She smoked 15 cigarettes per day for 40 years and she consumed small quantities of alcohol occasionally.
On examination
The patient seemed otherwise well. She was afebrile. Pulse 64/min regular. BP 140/80. RR- 16/min. Sats 98% on room air.
CVS: Heart sounds normal. Regular rhythm. No added sounds or murmurs. No peripheral oedema.
RESP: trachea central. Percussion resonant. Breath sounds vesicular.
ABDO: soft, non-tender, no hepatosplenomegaly, bowel sounds normal. No bruits. Aorta mildly expansile
CNS: Cranial nerves 2-12 normal.
PNS:
RUL LUL RLL LLLThe patient denied any back pain. There was no history of vertebral disc problems, no chest pain or abdominal pain. There were no palpitations. The patient denied symptoms of diabetes such as excessive thirst, blurred vision etc. There was no history of being previously unwell and there were no symptoms consistent with infection or bleeding.
The patient was a known hypertensive and took atenolol 25mg once daily.
She had no drug allergies. She smoked 15 cigarettes per day for 40 years and she consumed small quantities of alcohol occasionally.
On examination
The patient seemed otherwise well. She was afebrile. Pulse 64/min regular. BP 140/80. RR- 16/min. Sats 98% on room air.
CVS: Heart sounds normal. Regular rhythm. No added sounds or murmurs. No peripheral oedema.
RESP: trachea central. Percussion resonant. Breath sounds vesicular.
ABDO: soft, non-tender, no hepatosplenomegaly, bowel sounds normal. No bruits. Aorta mildly expansile
CNS: Cranial nerves 2-12 normal.
PNS:
Tone Normal Normal Normal Normal
Power 5/5 5/5 4+/5 4+/5
Reflexes
Biceps Normal Normal
Supinat Normal Normal
Triceps Normal Normal
Knee Normal Normal
Ankle Normal Normal
Sensation
Light touch- normal in upper limbs, decreased in lower limbs around ankles and buttocks.
Babinski sign was normal bilaterally.
Coordination of the lower limbs was not performed.
Vertebral examination was non-tender.
Over several hours the neurology worsened:
Light touch- normal in upper limbs, decreased in lower limbs around ankles and buttocks.
Babinski sign was normal bilaterally.
Coordination of the lower limbs was not performed.
Vertebral examination was non-tender.
Over several hours the neurology worsened:
RUL LUL RLL LLL
Tone Normal Normal Reduced Reduced
Power 5/5 5/5 3/5 3/5
Reflexes
Biceps Normal Normal
Supinat Normal Normal
Triceps Normal Normal
Knee Absent Absent
Ankle Absent Absent
Babinski sign became negative bilaterally.
Sensation
Light touch- normal in upper limbs, decreased in lower limbs up to the umbilicus (T10) region. Vibratory sense was intact on the pelvic brim and right knee but absent further down. Nociception and thermoreception were absent. Joint position sense was not performed.
Anal tone was reduced with an absent anal 'wink' sign.
In fact, the weakness progressed further resulting in paralysis of the lower limbs and bowel and bladder disturbance. However, light touch and vibratory sense were maintained although nociception and thermoreception remained absent. Joint position sense was interestingly absent.
Light touch- normal in upper limbs, decreased in lower limbs up to the umbilicus (T10) region. Vibratory sense was intact on the pelvic brim and right knee but absent further down. Nociception and thermoreception were absent. Joint position sense was not performed.
Anal tone was reduced with an absent anal 'wink' sign.
In fact, the weakness progressed further resulting in paralysis of the lower limbs and bowel and bladder disturbance. However, light touch and vibratory sense were maintained although nociception and thermoreception remained absent. Joint position sense was interestingly absent.
Questions
1) From history and examination, list the problems with this patient.
2) What immediate test or tests would you perform and why?
3) What anatomical problem is this from the history and physical examination?
4) What is the current evidence based treatment for such a condition?
The answer to this fascinating case will be published in the near future.
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