An 82-year-old, right-handed man with a long history of illness, was brought to the emergency room by his family; he was in acute distress with back pain and unable to walk.
History of Complaint
Patient experienced severe back pain radiating into both legs that remitted promptly when lying down. The next day he experienced similar transient pain in the back and the legs. Later that day, while experiencing an episode of severe back pain, his legs became paralyzed and he was rushed to the hospital.
Medical History
The patient had a previous history of transurethral prostatectomy and bilateral orchiectomv for carcinoma of the prostate, left hemicolectomv for adenocarcinoma of the rectum, and arteriosclerotic heart disease and congestive heart failure.
General Physical Examination
He was awake, cooperative, and afebrile and appeared older than his stated age. Funduscopic examination revealed bilateral ocular opacities obscuring visualization of the fundi.
External auditory canals were patent. No cervical lymphadenopathy was detected. Blood pressure was 160/90 mmHg, pulse rate was 48 beats per minute with occasional premature beats. There was a grade 2 blowing apical systolic murmur. Bilateral basilar crackles were present in the lungs on inspiration and bilateral jugular venous distention was demonstrable in the neck.
Peripheral pulses were intact and equal at the wrists and ankles. Pitting pretibial edema was present. A colastomy stoma was present in the lower left quadrant of the abdomen.
Otherwise the abdomen was soft to palpation with normal bowel sounds and no aortic bruits.
Neurologic Examination
Mental Status. He was alert and oriented to person, place and time; memory and affect were appropriate for his age. Speech was clear and meaningful. He was a good historian.
Cranial Nerves. His visual fields were intact and eve movements were full; hearing, to finger rub, was diminished bilaterally. His pupillary, corneal, and gag reflexes were intact: facial expressions were appropriate; uvula elevated symmetrically and tongue protruded on the midline. When asked, he could elevate his shoulders symmetrically with appropriate strength.
Motor Systems. His strength and muscle tone were absent in both lower extremities and deep tendon reflexes were absent at the knee and ankle. His strength and reflexes in the upper extremities were appropriate for his age. His urinary bladder was neurogenic, however, this had been present since his last surgery.
Sensory Exam. There was a well-defined sensory level at T10, below which he had lost sensation to pinprick and temperature. Touch, vibratory, and position sense were intact throughout his body and face.
Follow-up
He was treated with steroids and supportive measures without improvement. Five weeks after the onset of paraplegia he died from a sudden cardiorespiratory arrest.
☞ QUESTIONS
1. Does the patient exhibit a language or memory deficit or an alteration in consciousness or cognition?
2. Are signs of cranial nerve dysfunction present? If so are they signs of segmental or supersegmental dysfunction?
3. Are there any changes in motor functions, such as reflexes, muscle tone, movement, or coordination? If so are they signs of segmental or supersegmental dysfunction?
4. Are any changes in sensory functions detectable?
5. Based on the answers to the above questions, at what level in the neuraxis is this lesion most likely located?
6. Is the pathology focal, multifocal, or diffuse in its distribution within the nervous system?
7. What is the clinical-temporal profile of the neurologic pathology in this patient: acute or chronic; progressive or stable?
8. Based upon your answers to the above two questions describe the pathology occurring in this patient.
9. If you feel this patient’s pathology is the result of a vascular accident, what vessels are most likely involved?
