Intended for healthcare professionals

Endgames Case Review

A 51 year old woman with leg weakness after falling

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.k4773 (Published 03 January 2019) Cite this as: BMJ 2019;364:k4773
  1. Shlok Gupta, staff internist,, assistant clinical professor (adjunct)12
  1. 1Niagara Health System, St Catharines, ON, Canada
  2. 2McMaster University (Niagara Regional Campus), St Catharines, ON, Canada
  1. Correspondence to S Gupta shlok.gupta{at}niagarahealth.on.ca

A 51 year old woman presented to the emergency department after being found on the floor beside her bed—she had fallen and was unable to get up. She had no angina, palpitations, dyspnoea, nausea, diaphoresis, or loss of consciousness before, during, or after the fall. She reported difficulty passing urine for 4-6 weeks. Her history included hypercholestrolaemia, generalised anxiety disorder, and gastroesophageal reflux.

She had facial bruising and was unable to walk. Cardiopulmonary examinations were normal. Table 1 shows her strength examination results. Reflexes were 3+at the biceps, triceps, brachioradialis, patella, and Achilles tendons. Ankle plantar responses were upgoing bilaterally (Babinski sign) with spasticity in the legs and sustained clonus at the ankle. Hoffman sign was negative. Digital rectal examination revealed normal tone. Proprioception testing at the big toe was normal. Sensory examination was normal to light touch. Magnetic resonance imaging (MRI) was performed (fig 1).

Fig 1
Fig 1

T2 weighted MRI of the spine

Table 1

Strength examination results according to the Medical Research Council scale*

View this table:

Questions

  • 1. What is the anatomical location of the cause of this patient’s neurological signs?

  • 2. What is the most likely diagnosis?

  • 3. Why is MRI of the whole spine important in this case?

Answers

1. What is the anatomical location of the cause of this patient’s neurological signs?

Hyperreflexia, spasticity, upgoing ankle plantar response, and clonus suggest an upper motor neuron localisation.

Hand weakness suggests a cervical spine location.

Preservation of shoulder abduction and elbow flexion suggests that C4 and C5 are not affected.

Reduced strength wrist flexion and extension suggests that the lesion is at the C6 level.

This is confirmed by the MRI (fig 2).

Fig 2
Fig 2

T2 weighted MRI of the spine showing disk bulging and spinal cord compression at C5-6 and C6-7

2. What is the most likely diagnosis?

Cervical spondylitic myelopathy (CSM), which is compression of the cervical cord secondary to advanced osteoarthritis of the cervical spine. Examination findings suggestive of CSM are: a wide based, ataxic, or spastic gait; hyperreflexia of the biceps, triceps, patella, or Achilles tendon; sustained clonus; inverted supinator sign; Hoffman sign; Babinski sign; and urinary dysfunction.1

Three out of five of gait deviation, Hoffman sign, inverted supinator sign, Babinski sign, and age >45 years has a positive likelihood ratio of 30.9 (95% confidence interval 3.9 to 181.8).1

CSM is the most common cause of spastic paraplegia in people over 55.2 CSM is present in 5-10% of individuals over 65 who present with neck pain or radiculopathy secondary to degenerative disk disease (osteoarthritis) in the cervical spine.2 Individuals with CSM usually present to their general practitioner or emergency department and require a complete neurological examination to assess for myelopathy.

This patient also presented with urinary dysfunction. Spinal cord injury interrupts the brainstem signals coordinating detrusor contraction and sphincter relaxation, leading to “detrusor-sphincter dyssynergia.” This causes incomplete emptying, urinary urgency, and overflow incontinence. Spinal cord injury should be suspected in patients presenting with urinary dysfunction and limb weakness because innervation of the bladder arises caudal to innervation of the limbs; therefore, if the limbs are affected by spinal cord injury, the bladder will likely be affected as well.3

Differential diagnoses for all myelopathies include spondylosis (degenerative changes in the spine), epidural compression from abscess or haematoma, malignant compression, compression due to neurofibroma, pathological fracture, traumatic injury, subacute combined degeneration caused by severe B12 deficiency, and transverse myelitis.24567

Amyotrophic lateral sclerosis can mimic myelopathy because of hyperreflexia in the limbs, but will also present with muscle wasting and fasciculations, bulbar symptoms, and fasciculations in the tongue.

3. Why is MRI of the whole spine important in this case?

MRI identifies the aetiology and level of spinal lesions.

If physical examination shows that the cervical spine is affected, the patient may also have lesions in the thoracic or lumbar spine. These lesions could be due to spondylitic myelopathy or due to the differential diagnoses of CSM. Differential diagnoses of CSM include: epidural abscess or haematoma, malignancy, metastases, neurofibroma, spondylosis, pathological/traumatic fracture, and transverse myelitis.2457

If there is clear evidence that the cervical spine is preserved, but the legs are affected, then imaging of the cervical spine may not be necessary.

With epidural abscess and malignancy, compression is more likely to occur in the thoracic or lumbar cord than in the cervical cord.45

If there is suspicion of transverse myelitis, MRI of the brain is indicated to assess for multiple sclerosis.

Learning point

Examine patients with neck pain and radiculopathy for features of CSM.

Patient outcome

This patient was transferred to a tertiary centre for urgent surgical decompression of her cervical spine. She made a complete recovery.

Footnotes

  • The authors have read and understood The BMJ Education policy on declaration of interests and have completed The BMJ Education Declaration of Interests form. The BMJ has judged that there are no relevant competing financial interests.

  • Provenance and peer review: not commissioned; externally peer reviewed.

  • Patient consent obtained.

References

View Abstract

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