62yo M with difficulty walking

62yo M with difficulty walking
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(Paul Lin) #1

Hx - 62yo M presents with difficulty walking

PE - He has spastic weakness of the legs. It appears more spastic than weak. The tone is increased, the reflexes brisk with clonus and the plantar responses extensor. Vibration and joint position senses are lost in the lower limbs but no spinothalamic deficits. In the upper limbs there is asymmetrical abnormalities in the biceps and supinator reflexes - there are absent jerks with brisk finger flexion.

What is the likely diagnosis/cause?

(Daniel Guilfoyle) #2

Bilateral LL UMN findings + asymmetric UL mixed UMN/LMN up to C5-6
Dissociated sensory loss (DCML not STT in LL)
No mention cerebellar abn, cranial nerve or cortical findings
No mention systemic disease
No mention headache

Acuity unknown, crucial to guide DDx

Likely SC lesion around C5-6 ?transverse myelitis (demyelination v other inflamm) v syrinx v tumour v vasc malformation v hereditary (unlikely given age unless all findings chronic)

(Less likely brain lesion given bilateral findings and lack of cortical/CN/findings, degenerative or SSS thrombosis might be an unlikely cause… Would not account for dissociated sensory loss or lmn findings in upper limb)

Alternatively, if sensory findings are glove-stocking, consider dual pathology with e.g. ALS and peripheral length dependent neuropathy

(Paul Lin) #3

Agree, it’s probably cervical myelopathy. The inverted “midcervical” reflexes represents LMN signs around C5-6 with the reduced reflexes, and UMN signs below at C7-8 with increased triceps or finger jerks seen instead (also seen with Hoffmans test). This is where spinal canal is the narrowest.

The sensory exam may show dorsal column loss including a positive Rhombergs (so both ataxic and spastic gait) but pain and temp which are more lateral are spared.

The most common cause in this age group is cervical spondylosis, confirmed with MRI. Treatment is with analgesia, neck brace, laminectomy or discectomy.