Neurological Case 55—A 60y 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 friend’s wheelchair to get around outside because his legs ‘just wouldn’t hold him any more’.
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. 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 5kg in weight but on systemic enquiry there are no other symptoms.
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 fi ngers are not clubbed but they are tar-stained. There is a palpable bladder but no hepatomegaly; respiratory examination is unremarkable and no skin lesions are found.
His cranial nerves and upper limbs are entirely normal. In the legs, there is no wasting or fasciculations, and tone is increased bilaterally. He has great diffi culty lifting his legs off the couch, bending his knees or dorsifl exing his feet (power 3/5) and some diffi culty extending his legs at the hips,straightening his legs or plantar fl exing 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.