Case Studies
Case 8: An 84-year-old man with a six-month history of difficulty walking
A 84-year-old man gives a six month history of progressive difficulty walking due to pain and dragging of the legs. He has increasing neck pain which has been present for a number of years. When he starts to walk his legs feel generally fine although he has noticed that they jump a little bit at night. However as he walks his legs become heavier and finds them more difficult to use and they tend to drag. He has no major problems with his bladder or bowel, has no problems with his cranial nerves or upper limbs.
On examination he had normal cranial nerves. In the upper limbs he had reduced biceps and supinator jerk with a very brisk triceps jerk but no other abnormalities. In the lower limbs he has a spastic paraparesis with relatively well preserved power, brisk reflexes, extensor plantars and no sensory loss.
Your Answer:
Correct answer: Mid cervical myelopathy. In someone of this age it is very common for them to have degenerative change within the cervical cord. The progressive degenerative change leading to osteophyte formation and a degree of disc prolapse leads to compression of the cord causing upper motor neurone signs in the legs. In this case it is probably in the mid cervical region as there is some evidence that the C5/6 nerve roots are involved by virtue of the depressed biceps and supinator jerks whilst the brisk triceps jerk would imply that the lesion is compressing the cord just above C7 which is the root value of the triceps jerk.
Your Answer:
Correct answer: An MRI of his cervical spine.
Your Answer:
Correct answer: The differential diagnosis of a case such as this involves:
(a) some other mass lesion in the cervical cord region including a meningioma.
(b) B12 deficiency giving subacute combined degeneration of the cord.
(c) Dural fistula with an abnormal blood vessel causing vascular problems within the spinal cord.
(d) Motor neurone disease.
Although in the first 3 of these differential diagnoses there is typically sensory symptoms which are never part of motorneuron disease.
Sagittal T2 weighted image of the cervical spine with degenerative changes in all of the discs and posterior osteophytes which indent the cord particularly at C3/4 level where there is minor cord signal change (open arrow).