Intended for healthcare professionals

Endgames Case Review

A 51 year old woman with leg weakness after falling

BMJ 2019; 364 doi: (Published 03 January 2019) Cite this as: BMJ 2019;364:k4773

Re: A 51 year old woman with leg weakness after falling

This presentation of a 51-year-old woman with leg weakness after falling is misleading unfortunately. The M are I does show cord compression and signal change but this is not the full story. The pattern of presentation is key; a fall and acute inability to walk with hands weaker than legs. The diagnosis is a variant of acute spinal cord injury due to the pre-existing canal stenosis, typically referred to as "central cord syndrome ." It does occur on a background of clinical cervical spondylotic myelopathy, but often out of the blue in patients that have no history of neurological problems, as a consequence of a flexion/extension injury without a fracture.

In this case I would disagree with the need for MRI of the whole spine; the diagnosis is clearly localised to the lower subaxial cervical spine from the examination and whilst there may be "lesions" in other areas of the spine, in this context they are clinically irrelevant. The automatic and reflexive recourse to exhaustive imaging should not be encouraged unless it is evidence or clinically based.
The critical difference between central cord syndrome and cervical spondylotic myelopathy is the need for early immobilisation in the context of a possible flexion extension injury, and the unclear timing of surgery for either. They are very different clinical entities and one requires far more focus on rehabilitation, whereas cervical spondylotic myelopathy in its far more common, slowly progressive context, requires careful outpatient assessment and counselling.

Competing interests: No competing interests

04 January 2019
Matthew Crocker
St Georges university hospital London