An elderly male with subacute

onset of walking difficulty &

bladder dysfunction-Dr. W.A.P.R.S Weerarathna

Registrar WD 10/02

History

Mr. M, a 72 year old gentleman from

Jaffna presented to ED with the

complaints of tingling/numbness of

feet & difficulty in walking for five days

duration.

Difficulty in initiating micturition for 2

days & anuria for one day.

Experienced heaviness of legs but no

dragging of feet.

Mild burning pain associated with gradual numbness of feet evolving over 5 days.

H/O BOO & intermittent LUTS prior to this admission.

Constitutional symptoms- LOA/LOW

No H/O localized or radiating type of back pain

No recent H/O trauma to the back or fall from a height.

No H/O recent febrile/diarrhoeal illness

No associated numbness/tingling in the hands, SOB

No haemorrhagic diathesis

No H/O chronic cough, contact H/O PTB

No H/O bone pains, pathological fractures

No altered bowel habits apart from mild constipation

No history suggestive of raised ICP

PMH: CA Prostate in 2013-defaulted follow-up, no H/O Diabetes, Stroke, IHD

PSH: underwent prostatectomy

DH: had been on Flutamide 250 mg tds

FH: Not significant

AH: Nill

SH: smoker-five pack years, Ex-alcoholic, poor socioeconomic background & insufficient knowledge regarding his current illness.

Physical exam.

Conscious/rational

Not pale/icteric

BMI-22 kg/m2

Not febrile/dyspnoic

No body rashes

CNS

Spine/back-no

scars/deformities/tenderness

LL exam-

Inspection-no deformities/not wasted/no

fasciculations

R/S L/S

Tone increased

increased

Clonus-ankle/patellar- absent

Power prox. 3/5 3/5

distal 2/5 2/5

Reflexes KJ +++

+++

AJ ++

++

Plantars/Babinski up/+

up/+

Sensory system- sensory level at T7 /

pain & light touch absent below the

affected sensory level

Co-ordination-difficult to assess

JPS/vibration sense- impaired

impaired

UL exam- normal/ reflexes not

exaggerated

Cerebellar system- No cerebellar

signs in the UL

Fundoscopy – Normal/no papilledema.

CN exam- No focal neurological

deficites.

Other systemic examination

AS: No organomegaly

RS: No added sounds

CVS: BP- 130/80 mmHg, PR-88/min,

No AF, no detectable cardiac

murmers.

summary

A 72 year old gentleman with a H/O

CA prostate with defaulted follow-up

presented with subacute onset B/L

spastic paraparesis & urinary

retention. O/E he had sensory level at

T7 with no associated spinal deformity

or tenderness. The rest of the

systemic exam is unremarkable.

Differential diagnosis

Neoplastic spinal cord compression

due to metastatic prostatic

carcinoma/secondary deposits.

Acute transverse myelitis.

Spinal epidural abscess.

Investigations

CT SPINEExtensive vertebral body

metastasis from carcinoma of

prostate.

Mild vertebral collapse &

posterior bulging of the

vertebral body at T5 & T6 levels

No significant canal narrowing.

Normal vetebral curvature

maintained.

Multiple sclerotic

metastases from carcinoma

of prostate involving

cervical/thorasic & lumber

vertebrae.

Pelvic bone metastsis-

sclerotic/lytic

USS-Abdomen

Liver- normal echogenic pattern

Kidneys-normal

Prostate-not visualized clearly

Bladder- empty,catheter bulb insitu

No abnormalities detected.

PSA

Total PSA > 100 ( NR 0-4 ng/dl)

Other basic investigations

CBC- hb-11.9 g/dl, WBC-21.9/ N-

83.6%/Hct-36/ MCV-82.7/PLT-353000

RFT- NORMAL

LFT/PT-INR-NORMAL

UFR-pro ++/ WBC- FF

S.Ca-pending

Discussion…….

Thank you!