Case 2 A 60-year-old man with back pain
and weakness
Arthur is a 60-year-old who presents with a 2-month history
of new onset back pain. He originally attributed it to the
bad weather but it did not improve despite regular
analgesics. When it started, he had no additional symptoms,
and his GP prescribed some stronger painkillers and asked
him to come back in a month if it hadn’t gone away. When
he returned to the GP, his pain was worse and he had great
difficulty walking into the surgery; he had borrowed a
PA R T 2 : C A S E S
friend’s wheelchair to get around outside because his legs
‘just wouldn’t hold him any more’.
What are the key features of
the history?
1 Where is the pain and does it radiate anywhere?
• Back pain with nerve involvement may radiate
down the buttocks and into the legs or feet
2 Are there any exacerbating or relieving factors?
• Coughing, sneezing and straining may worsen
pain associated with nerve root compression
(radiculopathy)
3 Does he have any new symptoms of bowel or bladder
dysfunction?
• Urinary retention
• Hesitancy
• Frequency
• Constipation
• Incontinence
If present, these are extremely worrying ‘red flag’ symp-
toms which can indicate spinal cord or cauda equina
compression, and require urgent attention
4 Does he have normal sensation during micturition or
defaecation?
5 What is the duration of symptoms and how fast are
they progressing?
Neurology: Clinical Cases Uncovered, 1st edition. © M. Macleod,
M. Simpson and S. Pal. Published 2011 by Blackwell Publishing Ltd.
22
• This gives a suggestion as to the likely aetiology and
may dictate the urgency with which investigations are
required
6 Does he have pain, weakness or altered sensation in his
legs? Does he have disturbance of balance?
7 Are there any neurological symptoms in the hands or
the cranial nerves?
• This is essential information in localising the lesion.
Involvement of both hands and both legs suggests a
lesion in the cervical spinal cord (or peripheral nervous
system); involvement of only the legs suggests a lesion
in the thoracolumbar spinal cord (or peripheral
nervous system). Involvement of the cranial nerves
places the lesion higher up in the brain or brainstem,
or suggests a diffuse process
8 Is there a band-like sensory level around his trunk?
• If present, this is a very strong indicator of spinal
cord pathology and may help localise the site of the
lesion
9 Are there any symptoms of systemic disease or risk
factors for malignancy, or a history of arthritis?
• Where cord compression is a consideration, the two
most common causes are metastatic malignancy and
spondylosis
Arthur reports that the pain is in the middle of his back, just
below the bottom of his rib cage, and that it does not
radiate anywhere else but has been becoming progressively
more severe over the last month. He didn’t want to come
back to the doctor’s early because he didn’t want to take up
her time. He has been constipated but he put that down to
the medication, and he has been getting up several times
each night to empty his bladder, although lately he has not
been able to pass more than a few drops of urine and still
feels that his bladder is not completely empty afterwards.
His legs have felt ‘heavy’ for the past 10 days and over the
past 2 days he has noticed some tingling in his feet on both
sides. His walking has deteriorated too, and he is now able
to walk only 50 m with great difficulty.

He has been feeling less well in general over the last
few months; he has been tired and sometimes breathless,
although he put this down to his smoking habits. He used
to smoke 20 cigarettes per day but gave up 2 months ago
because he just didn’t feel like it any more. He has lost 5 kg
in weight but on systemic enquiry there are no other
symptoms.
What is the differential diagnosis at
this point?
!RED FLA G
His history is worrying because of the progressive nature
of the pain and the development of leg weakness. The
presence of bowel and bladder disturbance and sensory
changes in the feet are also very worrying and should alert
the neurologist to the possibility of spinal cord or cauda
equina pathology. Given his systemic symptoms, a
malignant cause is likely.
Neurological examination will help to further localise the
site of the lesion. The main differential is between a lesion
in the spinal cord (upper motor neuron), in the nerve
roots around the cauda equina, or the peripheral nervous
system (lower motor neuron), although bladder involve-
ment would not be expected with a lesion in this area.
What are the key features of
the examination?
General examination
Where malignancy is suspected, it is important to look
for any clinical signs of it:
• Cachexia or signs of weight loss
• Finger clubbing
• Lympadenopathy
• Jaundice
• Pallor
• Pleural effusion or pulmonary collapse
• Abdominal masses or organomegaly
• Breast masses or axillary lymphadenopathy
• Skin lesions or rashes
Cranial nerves and upper limbs
It is important to examine both of these carefully, regard-
less of the fact that the complaint involves the legs, as it
may change the location of the presumed neurological
lesion if these are found to be abnormal.
Case 2 23
Lower limbs
1 Tone: if increased, it is suggestive of an upper motor
neuron lesion (although there may be flaccid weakness
in the acute phase of a spinal cord injury).
2 Power:
• Is there weakness, is it bilateral or symmetrical, and
what is the distribution?
• In lesions of the pyramidal tracts (i.e. the long motor
pathways of the brain and spinal cord), there may be
a characteristic pattern of weakness where the flexors
(hip flexion, knee flexion, ankle dorsiflexion) of the
legs are weaker than the extensors (hip extension, knee
extension and plantar flexion). In the arms, the pattern
is reversed and the extensors are weaker than the
flexors
• In lesions of the peripheral nervous system, weak-
ness may be patchy (as in mononeuritis multiplex) or
may be more marked distally (as in a length-dependent
PA R T 2 : C A S E S
peripheral neuropathy)
3 Coordination: this may be abnormal as a consequence
of the weakness rather than as a result of primary abnor-
mality of the cerebellum; if there is definite weakness
examining coordination may be unreliable.
4 Sensation: it is essential to examine sensation in the
legs and trunk and to document the presence or
absence of a sensory level, which can be extremely helpful
if present. It is also essential to look for differences
between pain/temperature (which are transmitted in
the spinothalamic tracts) and vibration/proprioception/
light touch (which are transmitted in the dorsal columns)
as a difference in these groups of modalities might
help localise a spinal lesion to a particular part of the
spinal cord. It is important to map out the distribu-
tion of sensory change, and to assess whether it fits
with a particular dermatome or peripheral nerve (Fig.
2.1).
5 Reflexes: in disease of the spinal cord (other than the
acute phase where there may be flaccid weakness and
areflexia), the reflexes are likely to be brisk and there may
be upgoing plantars. Nerve root compression may lead
to absent reflexes in the nerve involved. In diseases of the
peripheral nervous system where there is demonstrable
weakness on examination (indicating moderately severe
nerve dysfunction), the reflexes are likely to be absent or
very difficult to elicit; plantars are likely to be downgoing
or equivocal.
6 Gait: this is useful because it gives an idea of the
patient’s functional status as well as helping to localise
the neurological lesion.
 24 Part 2: Cases

C2

C2 C3

C4
C3 T2 C3
T3 C4
C4 T4
C5 T2 T5 T2
T3 C5
T6
T4
T7
T5 T8
T6 T2
T2 T9
T7
T8 T10
T1 T9 T11
C6
T12 T1
C6 T10
L1
T11 L2
T12
S4
L1 S5 C6
S3 S3
C8 S4
C6 C7 C8
C7
PA R T 2 : C A S E S

L2 L2
S2
L3

L3

L5 L4
L5

S1
L4

S1 S1

L5 L5
Figure 2.1 The dermatomes.

Table 2.1 Nerve roots responsible for deep tendon reflexes.
Reflex
Biceps
Brachioradialis
Triceps
Knee
Ankle
Table 2.1 shows the nerve roots that mediate the com-
monly tested deep tendon reflexes. A useful scheme for
documenting the lower limb power is shown in Table 2.2.
On general examination, Arthur is thin, with sunken cheeks
and his trousers are held together with a piece of string
because they have become loose. His fingers are not
clubbed but they are tar-stained. There is a palpable bladder
but no hepatomegaly; respiratory examination is
Root unremarkable and no skin lesions are found.
His cranial nerves and upper limbs are entirely normal. In
C5, C6
the legs, there is no wasting or fasciculations, and tone is
C6, C5
increased bilaterally. He has great difficulty lifting his legs off
C6, C7
the couch, bending his knees or dorsiflexing his feet (power
L3, L4
S1 3/5) and some difficulty extending his legs at the hips,
straightening his legs or plantar flexing his feet (4/5). The
coordination could not be tested because of this. The
reflexes were brisk and symmetrical and there was clonus at
the ankle bilaterally. The plantars were bilaterally and
symmetrically upgoing, and there was sensory loss to all
modalities up to the level of the umbilicus. On digital rectal
examination there was reduced anal tone and decreased
perineal sensation. He had pain on percussion of his back in
the mid thoracic region.
 Case 2 25

Table 2.2 Useful scheme for documentation of limb

examinations.
Box 2.1 Causes of spastic paraparesis

Right lower limb Left lower limb • Neoplastic: metastatic tumour, intrinsic spinal cord
tumour (rarely due to intracerebral parasaggital
Tone ↑↑ ↑↑ meningioma)
• Degenerative: spondylytic changes secondary to
Power: osteoarthritis
Hip flexion 3/5 3/5 • Vascular: spinal artery infarction, haemorrhage (from
Hip extension 4/5 4/5 spinal arteriovenous malformation or arteriovenous
Knee flexion 3/5 3/5 fistula)
Knee extension 4/5 4/5 • Inflammatory: demyelination secondary to multiple
Ankle dorsiflexion 3/5 3/5 sclerosis or neuromyelitis optica
Plantar flexion 4/5 4/5 • Toxic and metabolic: e.g. vitamin B12 deficiency, nitrous
Great toe 3/5 3/5 oxide poisoning
Coordination n/a n/a • Infective: HIV, HTLV-1
• Hereditary: hereditary spastic paraparesis, Friedrich’s
Sensation ↓ all modalities to ↓ all modalities ataxia
umbilicus to umbilicus

Reflexes:

PA R T 2 : C A S E S
Knee jerk ++++ ++++
Ankle jerk +++ +++
Plantar response ↑ ↑

What is the most likely diagnosis now?
The history suggests a subacute onset of back pain, dif-
ficulty mobilising, leg weakness and sphincter distur-
bance. The signs on examination are suggestive of an
upper motor neuron lesion with increased tone, a pyram-
idal pattern of weakness and hyperreflexia with clonus;
this is the clinical picture of a spastic paraparesis (Box
2.1). The absence of any findings in the arms or cranial
nerves, together with the presence of a sensory level,
strongly suggest spinal cord pathology. In a patient of this
age group, the most likely diagnosis would be malignant
cord compression (particularly in the presence of sys-
temic features of malignancy). Spondylitic disease is also
a possibility. In any case, urgent neuroimaging is required
to investigate this further.
C AS E R E V I E W
This case describes the classic clinical picture of spinal
cord compression, which is a true neurological emer-
gency. The key ‘red flag’ symptoms which should alert
the neurologist in this case were the combination of back
pain with weakness and the presence of urinary distur-
bance, together with the band-like sensation characteris-
tic of a sensory level. The clinical examination confirmed
an upper motor neuron pattern of weakness, and urgent
spinal imaging was indicated as treating this condition
early may prevent paralysis.

Arthur is rushed to the radiology department for urgent KEY POINTS

imaging of his spinal cord (Fig. 2.2). This confirms the
neurologist’s suspicion of malignant cord compression and
he is treated immediately with high-dose intravenous
steroids. A chest X-ray shows a suspicious lesion and
following bronchoscopy he is diagnosed with small cell
carcinoma of the lung. He receives radiotherapy to the
spinal cord metastasis and is commenced on chemotherapy
to treat the underlying cancer. At his 3-month review he is
still ambulating and is free from back pain.
• Suspected spinal cord compression is a neurological
emergency and requires urgent diagnosis and
treatment
• Bladder disturbance, leg weakness and the sensory level
are ‘red flag’ symptoms and signs that should raise
alarm
• Early treatment of spinal cord compression with steroids
or surgery may prevent paralysis
 26 Part 2: Cases
PA R T 2 : C A S E S

(a) (b)

Figure 2.2 MRI showing malignant cord compression in the thoracic spine.

Further reading and references

Abrahm JL, Banffy MB, Harris MB. Spinal cord compression in
patients with advanced metastatic cancer: ‘all I care about is
walking and living my life’. JAMA 2008;299(8):937–46.