A 51 year old woman with leg weakness after falling

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).