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| IMAGE QUIZ ARCHIVE | ||||||
| Image Quiz | ||
| Rapid Onset of Severe Low Back Pain and Lower Extremity Paralysis1 | ||
| A sixty-five-year-old woman had acute, but transient, neck pain following a short coughing episode. The patient was able to walk to the restroom, where she began to have severe low-back pain and lower extremity numbness and weakness that rapidly progressed to frank lower extremity paralysis. While en route to the hospital, the patient became incontinent of both bowel and bladder. Upon admission to the emergency department, the patient complained of low-back pain, bilateral hip and thigh pain, and the inability to move or feel the lower extremities. The emergency department staff obtained an urgent orthopaedic consultation to evaluate the patient for an acute cauda equina syndrome. | ||
| The patient had no relevant medical or surgical history, was not taking any medications, and denied any family history of medical illnesses. She reported that she had smoked more than one pack of cigarettes per day for more than forty years. On review of systems, the patient repeatedly denied having had any syncope, vision changes, chest or thoracic pain, shortness of breath, upper extremity symptoms, or abdominal pain. She did report nausea, vomiting, diaphoresis, low-back pain, buttock pain, thigh pain, decreased sensation in the lower part of the trunk and lower extremities, and an inability to move the lower extremities. | ||
| The measurement of vital signs revealed a blood pressure of 179/86 mm Hg, a pulse rate of ninety-five beats per minute, and a respiratory rate of eighteen breaths per minute. The patient was crying and complaining of pain and weakness. The lower extremities were warm and pink and were insensate to light touch, proprioception, and pain from the second lumbar level caudally. The patellar and Achilles tendon reflexes were absent, there was no clonus, and the Babinski signs were negative. Muscle strength was grade 0 of 5 for all motor groups from the third lumbar level caudally. The patient had no rectal tone, was incontinent of stool, and, while the bulbocavernosus reflex was absent, there was no evidence of sacral sparing. The femoral, popliteal, dorsalis pedis, and posterior tibial pulses were neither palpable nor detectable on Doppler examination. | ||
| A computerized tomographic scan of the abdomen was performed. | ||
 Fig. 1 |
 Fig. 2 |
For larger view, click on image |
| What is the diagnosis? | ||
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