1997 Exam I Case 01

Chief Complaint

A 55-year-old right-handed male with intense abdominal pain and paralysis.

History of Chief Complaint:

He had experienced a diffuse abdominal pain for several days prior to admission (PTA). One day PTA, he developed severe abdominal pain that radiated into flank, sacral region and scrotum while straining at stool. He presented to the emergency room (ER) the following morning when the pain did not remit. During his stay in ER the pain worsened and he developed complete paraplegia and loss of bladder function. He denies any dizziness or nausea. He denies any dysphagia; he complains of a feeling of shortness of breath.

Medical History:

Diagnosed with an abdominal aortic aneurysm five years ago.

Surgical History:

none

Allergies:

none

Medications:

none

Physical Exam:

This is an alert, anxious male in obvious acute distress. He is 5'10" and weighs 265 lbs. His blood pressure is 140\95, pulse is regular at 84 bps, respirations are 19 bpm, and temperature is 99¯. Carotid bruits are present bilaterally in the neck. Lungs are clear to auscultation. Abdominal guarding is present and there is tenderness to palpation. A loud blowing abdominal bruit is present. Extremities are four in number, no clubbing, cyanosis or edema is present.

Neurologic Exam:

Patient is awake and oriented to person, place and time. He is in obvious distress from abdominal pain.

Cranial nerves: He has a full range of eye movements and his visual fields are full to confrontation. Pupillary response is intact bilaterally. There is no loss of sensation from the face and facial expressions are complete. Corneal and gag reflexes are intact. Hearing to finger rub is intact in both ears and his tongue protrudes on the midline. Power in shoulders and neck is intact.

Motor exam: Power is intact in the upper extremity. In the lower extremity strength was 0/5 bilaterally in the thighs, 0/5 at the right knee and 1/5 at the left knee; and 1/5 at the ankles bilaterally. There is no resistance to passive range of motion in either lower extremity and palpation of the muscles finds a lack of tone. Finger-to-nose testing was normal in the upper extremities and could not be tested in the lower extremities.

Reflexes: Reflexes are intact in the upper extremity. In the lower extremity, deep tendon reflexes were absent at the knee and trace at the ankle bilaterally.

Sensory: All systems are intact in the upper extremities. Vibratory sense, position sense and two-point discrimination are intact in both lower extremities. There is a dense bilateral band of analgesia beginning at T12 and continuing in both lower extremities.

Follow Up:

He received surgical intervention to repair the abdominal aneurysm. Two months following surgery his neurologic evaluation finds a mild sensitivity to pin prick has returned in the perianal region, the gluteal region and on the posterior aspect of his legs down to the ankles. He continues to lack any strength in the lower extremities. Deep tendon reflexes about the knees are absent and about the flexors and extensors of the ankles are +4 bilaterally. Clonus is elicited from the ankle on extreme dorsiflexion. He continues to experience incontinence; his bladder periodically empties 100-200 cc without warning. There is no dribbling at rest, however, he occasionally triggers a release when coughing.

Questions

INSTRUCTIONS: Provide the BEST or MOST LIKELY answer to the following multiple choice questions.

1) The motor deficit present in this patients lower extremity at the time of evaluation is best described as:

a. Flaccid paralysis

b. Spastic paralysis

c. Sensory ataxia

d. Dyskinesia

e. Clonus

ANSWER

2) The motor deficit in the flexors and extensors of the ankle on the Follow Up is best described as:

a. Flaccid paralysis

b. Spastic paralysis

c. Sensory ataxia

d. Dyskinesia

e. Clonus

3. The analgesia expressed in the torso and on the anterior surface of the lower extremity is most likely the result of destruction of the:

a. Peripheral nerves

b. Dorsal horn

c. Ventral horn

d. Anterior white comissure

e. Anterior lateral tract

4. The analgesia expressed in the perianal region and on the posterior surface of the lower extremity is most likely due to compression of the:

a. Peripheral nerves

b. Dorsal horn

c. Ventral horn

d. Anterior white commissure

e. Anterolateral tract

5. The incontinence experienced in this patient on Follow Up is best described as:

a. Flaccid bladder

b. Spastic bladder

c. Structural incontinence

d. Ataxic bladder

e. Dystonic bladder

6. In this patient, chomatolytic cell bodies will most likely be present in the:

a. Dorsal root ganglia below L4

b. Dorsal horn below L5

c. Dorsal root ganglia above T12

d. Dorsal horn above T12

e. Ventral horn below S1

7. In this patient, degenerating axons will most likely be present in the:

a. Corticospinal tract below S2

b. Fasciculus gracilis above T12

c. Medullary medial lemniscus

d. Medullary corticospinal tract

e. Sacral nerve roots S2-S4

8. The most likely location for this lesion on the neuaxis is:

a. Caudal medulla

b. C4 - T1

c. T5 - L1

d. T12 - L5

e. L5 - S5

9. The best description of the distribution of this lesion is:

a. Focal

b. Multifocal

c. Diffuse

10. The best description of the temporal profile of this lesion is:

a. Acute and stable

b. Acute and progressive

c. Chronic and stable

d. Chronic and progressive

11. The artery most likely involved in creating this lesion is the:

a. Subcortal artery

b. Vertebral artery

c. Posterior spinal artery

d. Radicular artery

e. Great medullary artery

ANSWER

IMPORTANT NOTE: This case assumes that the lesion is confined to 1-2 segments of the spinal cord; more typically in these types of cases the lesion is much more extensive involving the entire distal end of the spinal cord from T8 or T10 down.