Intended for healthcare professionals

Endgames Spot Diagnosis

A middle aged man with back pain and heavy legs

BMJ 2019; 366 doi: (Published 17 July 2019) Cite this as: BMJ 2019;366:l2420
  1. Neil Chanchlani, clinical research fellow1,
  2. Nick G Reading, consultant radiologist2
  1. 1Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
  2. 2Barts Health NHS Trust, London, UK
  1. Correspondence to N Chanchlani nchanchlani{at}

A 50 year old man presented with a two day history of “heavy legs,” reduced sensation bilaterally in his lower limbs, and five days of constipation. He had also experienced right upper quadrant pain for one month, and had a history of mechanical lumbar back pain for the preceding six weeks

His abdomen was mildly distended and diffusely tender. Rectal examination revealed packed faeces. He was able to walk, but dragged his legs and had bilateral global lower limb muscle wasting. Power grade in both lower limbs was 4/5 (proximally and distally) and he had bilateral hyperreflexia. He had reduced sensation in both lower limbs at L4, L5, and …

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