Case 46: ?cauda equina syndrome

posted: November 1, 1999

resident: Jay Howington, MD
attending: Rand Voorhies, MD

CLINICAL PRESENTATION: 35 year old woman presented to the ER with increasing low back pain; one episode of bowel incontinence and she "could not feel wiping herself" on the day of presentation. Some difficulty with walking- tightness in the legs and "balance off" for one week. Numbness in the right leg, but no leg pain.

EXAMINATION: Examination revealed a healthy appearing woman in no significant distress, BP: 130/85, P: 84; RR:18; T: afeb. General examination normal Awake/alert/oriented X4; memory and speech intact. Cranial nerves II-XII intact bilaterally; Motor exam: 5/5 bilateral; normal tone; normal rectal tone. Sensory exam: hypesthesia on the right side of the body; decreased graphesthesia and sterognosis on the right side; no senosory extinction. Good perianal and perineal sensation. Hyper-reflexia on the right side with an extensor plantar reflex on the right.

MRI exam of the lumbar spine revealed only mild mid-lumbar stenosis; no thecal sac compression.

What is the next study you would order; what is differential diagnosis?

Please comment: dawast@lsuhsc.edu

STEPS TAKEN AT LSUHSC: A MRI scan of the brain with and without contrast was ordered; select views are shown below:

A T2WI (left) and FLAIR image (right) show white matter changes (red markers). The image on the right shows the changes in the periventricular region.

After this scan, a lumbar puncture was performed and the CSF studies were consistent with a diagnosis of MULTIPLE SCLEROSIS

The patient was transferred to the Neurology service for further management.

Comments and Questions about this interesting case are welcomed. Please e-mail: dawast@lsuhsc.edu

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