MOC June 2015: I Would Rather Walk on Hot Coals Than To Feel Nothing

Chief Complaint: Foot numbness

History of present illness: 40 y.o. female with a history of obesity, elevated BP (taking hydrochlorothiazide) and s/p cholecystectomy who presents to the ED via EMS from a nearby hospital for evaluation of a foot numbness.

The patient awoke around 0530 this morning to use the bathroom and suddenly developed epigastric abdominal pain that radiated to her back. Shortly after, she developed numbness and tingling down her legs bilaterally below the knee along with a burning sensation down the back of her legs, which immediately resolved.  She was able to ambulate initially, but had decreased sensation of the bottoms of her feet.  Then, around 0830, she was unable to walk and her family was unable to get her out of bed due to inability to feel the feet at all, which prompted them to call EMS.  On her way to the hospital, she denies having any pain, only the continued loss of feeling in her feet.  The patient does admits she did sustain a fall a couple weeks ago. 

She was seen at her small local hospital, evaluated, and there was concern for spinal cord etiology.  Immediately, Neurosurgery was consulted and the patient was evaluated via teleconference; which then the patient was sent immediately to a facility via EMS which could MRI her to evaluate her spinal cord.   

At time of presentation to the accepting ED, the patient continued to be pain free.  No chest pain, no back pain, no headache, no leg pain, or foot pain.  However, the patient did continue to have numbness her entire foot bilaterally.  The patient denies any history of back problems, surgeries, leg problems, fevers, chills, headache, sore throat, chest pain, shortness of breath, nausea, vomiting, incontinence, loss of sensation of buttocks or genital area, or any other concerns or complaints at this time.

She has been taking her HCTZ for some time for her BP which has been well controlled; otherwise, no changes have been made in her medical treatment recently, other than placement of a Mirena IUD four days ago. 

Social Hx: Nonsmoker. No alcohol use.

Allergies:  NKDA

Medications: Hydrochlorothiazide

Medical History:

Elevated blood pressure

Obesity (BMI 30-39.9) 

Family history: Premature coronary heart disease

Past Surgical History:

Dilation and Curettage 2009

Cesarean Section 2010

Cholecystectomy 2012

Family / Social History:

Father: Diabetes, HTN, Cholesterol

Mother: Bleeding Problems (unknown what kind)

Sister: Diabetes

Smoking Status: Never Smoker

Alcohol Use: No

Review of Systems:

General: No fever, no general weakness, no appetite changes
Lungs:  No cough, no SOB
Chest:  No chest pain.  No Palpitations
Musc:  No back pain, no leg pain, no foot pain
Neuro:  No headache, loss of feeling to bottom of both feet, difficulty walking

First Vitals:

Temp: 99.9 °F (37.7 °C) BP: 171/81 mmHg Pulse: 75 Resp: 16 SpO2: 98 % Wt.: 98.431 kg (217 lb) Height: 162.6 cm (5' 4")

Physical Exam:

Constitutional: She is oriented to person, place, and time and well-developed, well-nourished, and in no distress.

HENT:  Normocephalic and atraumatic. External ears normal. Nose normal. Oropharynx is clear and moist.
Eyes: Conjunctivae are normal. Pupils are equal, round, and reactive to light.
Neck: Normal range of motion. Neck supple.  No meningismus.
Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Exam reveals no murmur. Femoral Pulses present bilaterally, possibly less on the left.
Pulmonary: Effort normal and breath sounds normal. No respiratory distress.
Abdominal: Soft. There is no tenderness. No guarding
Genitourinary: Deferred initially due to no complaint of saddle anesthesia.
**see rectal exam in ED course**
Musculoskeletal/Neurological: She is alert and oriented to person, place, and time.
Decreased sensation to bilateral lower extremities below the knee. Unable to move her feet bilaterally. Zero babinski reflex. Hyporeflexia of bilateral patellar reflex. Left leg feels cold to touch. Right leg warm to touch. Equal grip strength and sensation intact in upper extremities.  Equal Dorsal Pedal Pulse. Sensation intact at knee level and above (this is new since transfer).   
Skin: Skin is warm and dry. No erythema.
Psychiatric: Mood, memory, affect and judgment normal.

Differential Diagnosis:  Compressive myelopathy from neoplasm, Epidural or subdural hematoma, or Abscess, Spinal cord compression from herniated disc, Cauda Equina, Spinal AVM, Transverse myelitis, Acute polyneuropathy (eg, Guillain-Barré Syndrome (GBS)), Spinal cord infarction, MS, Brain neoplasm, Meningitis.

Most concerning etiology are the spinal cord lesions that can be compressing the cord requiring emergent decompression before loss of function!!! 

Immediately, an MRI of the Lumbar and Thoracic spine was obtained…..

Imaging:

MR Lumbar Spine Without Contrast:
1. Transitional lumbosacral anatomy is identified. The transitional segment is designated as a partially lumbarized S1 vertebral body, for the purposes of this examination. Based on this designation, the first nonrib-bearing vertebral body is L1. Careful correlation radiographs is recommended prior to any intervention.
2. Minor spondylitic changes, without significant spinal canal or neural foraminal compromise.
3. Mild bilateral hydronephrosis in the setting of urinary bladder distention.

MR Spine Thoracic With and Without Contrast:

1. Mild spondylitic changes, with left central disc extrusion at T8-T9 mildly effacing the left ventral thecal sac and minimally deforming the spinal cord, without accompanying cord signal abnormality. There is no evidence of significant spinal canal or nerve root compromise in the thoracic spine region.
2. No convincing abnormal signal intensity within the spinal cord. Consider thin section T2 imaging through the area of interest (centered at T10) and contrast administration for further characterization.

OH NO!!!!!!!!!

When patient returned to the ED, and was re-evaluated, she had loss of sensation and movement of her entire lower extremities bilaterally!  Rectal exam performed, and she had no sphincter tone, and as she rolled onto her back after the exam, she urinated all over herself unknowingly.   

After immediate consultation with the Neurosurgeon, she immediately went back to MRI…..

MR Brain With and Without Contrast:

1. Unremarkable MRI of the brain, without contrast.
2. Mild inflammatory mucosal disease scattered throughout the paranasal sinuses.

MR Spine Cervical With and Without Contrast:

1. Subtle linear T2 prolongation involving the ventral thoracic cord at the level of T4-T5, without associated postcontrast enhancement. Findings may be related to the noted linear ventral enhancement involving the conus medullaris delineated on lumbar spine MRI. Differential considerations include demyelinating disease, early acute cord ischemia, and transverse myelitis. Please refer to the report associated with dedicated thoracic and lumbar spine MRI examination for further details.
2. No evidence for cervical spinal cord lesion, signal abnormality or abnormal enhancement.

 
 
 
 

Although the patient presented without any chest or back pain, her initial complaint of pain was concerning for dissection.  Therefore, CT ordered….

CT Chest Abdomen Pelvis Aortic Dissection With Contrast:

1. No aortic dissection and no pulmonary embolism.
2. Very mild patchy groundglass infiltrates left upper lobe are nonspecific but could be due to a mild infectious or inflammatory pneumonitis.
3. Hepatic steatosis. Cholecystectomy.
4. Foley catheter in a decompressed bladder.
5. Chronic focal cortical scarring left kidney, kidneys otherwise negative.

Are we looking for a needle in a hay stack? 

Lab Findings:

CBC:

WBC 9.1 HGB 14.5 HCT 41.9 MCV 92 MCH 31.7 MCHC 34.6 RDW 14.3 PLT 106 L

 

BASIC METABOLIC PANEL:

SODIUM 140 POTASSIUM 3.7 CHLORIDE 112 H CO2TOTAL 19 L ANIONGAP 9 BUN 11 CREATININE 0.81 GLUCOSE 131 H CALCIUM 9.3 MAGNESIUM 1.9

GFR: GFRAFRICAN >60 GFRNOTAFRICA >60

INR:

INR 1.1

CSF RESULTS:

CSFCLARITY Clear CSFCOLOR Colorless RBCCSF 26 H WBCCSF 1 NEUTSCSF 0 LYMPHSCSF 92 H PROTEINCSF 40 GLUCOSECSF 48

All of the patient’s imaging was normal in the ED.  The patient had a normal lumbar puncture.  The patient has complete loss of sensation and function of her lower extremities that rapidly progressed while in the ED.   The patient was then admitted to the Neuro ICU for continued evaluation, and work up.  While in the ICU the patient received IV steroids and had follow up imaging. 

During hospital stay, serial follow up radiology tests were consistent with spinal cord infarction.  Lytic therapy was not an option given unknown time of onset, or “wake up stroke.”  Transesophageal echocardiography was done, with no gross reason foremboli.  The patient was eventually discharged to a TCU for rehabilitation, was started on an ASA and SSRI. 

Final Impression:

Spinal Cord Stroke

T10 Paraplegia

Let’s Talk About It!!!

1.      Which process is typically associated with an evolution of myelopathic symptoms over hours and days, but these can develop in as short a period as 10 minutes?

a.       Multiple Sclerosis

b.      Transverse Myelitis

c.       Peripheral Neuropathy

d.      Cauda Equina

e.      Spinal Cord Infarction

2.      Which process is can be confused with acute myelopathy because both are associated with flaccidity and loss of reflexes in the acute stage?

a.       Spinal Cord Hematoma

b.      Spinal AVM

c.       Guillain-Barré Syndrome

d.      Spinal Cord Infarction

e.      Pseudo Seizure

3.     In the postoperative setting, the differential diagnosis of paraplegia includes _______, especially if the patient has had either a lumbar drain or epidural anesthesia.

a.       Peripheral Neuropathy

b.      Cauda Equina

c.       Aortic Dissection

d.      Epidural Hematoma

e.      Spinal Abscess

 

4.      What is the BEST imaging to do in a patient with new onset, and rapidly advancing neurologic deficits in the lower extremities?

a.       CT head with and without contrast

b.      MRI lumbar spine with and without contrast

c.       MRI Lumbar and Thoracic without contrast

d.      MRI brain

e.      Ct Chest/Abd/Pelvis to rule out dissection

Follow up:  Unfortunately, this patient is a paraplegic for life.  Just turning 40 in the past year, and looking forward to many more years of an active life-style with her husband and three children.  Unfortunately,  there is no treatment options for a wake up spinal cord stroke.  However, everything was well thought out, and all bases covered, so that if there was something treatable, it would have been found.