Dr. Md Rashedul Islam FCPS, MRCP(UK)

Registrar, Neurology, BIRDEM

Presenting Complaints:

A 66 years old diabetic, right handed, gentleman,

hailing from Keraniganj, Dhaka got admitted in BIRDEM

General Hospital on 12th February,15 with the

complaints of-

• Difficulty in walking for 1 month• Retention of urine for 2 days

H/O Present illness

According to the statement of the patient, he was reasonably well 1 month back. Then he developed difficulty in walking which was gradual on onset associated with low back pain. His back pain was dull aching in nature, mild in severity with radiation to left lower limb, aggravated by walking, movement, change of posture relieved by taking rest. It was not associated with fever, cough, weight loss, alternation of bowel habit, h/o trauma.

H/O Present illness

He also had complaints retention of urine which was sudden on onset associated with abdominal discomfort. He was catheterized outside BIRDEM. He didn’t have complaints of urgency, hesitancy, frequency of micturation.

H/O past illness:

Nothing contributory

Socioeconomic history:

He belongs to a middle class family

Personal history:

He is non alcoholic, non smoker

Family history:

Nothing significant

Treatment history:

Insulin

Tab. Vit B complex

General examination:

Appearance: ill looking, anxiousBuilt: average Decubitus: on choiceAnaemia ++JaundiceCyanosisOedemaDehydrationClubbingKoilonychiaLeukonychia

Absent

General examination:

Neck vein: not engorged

Thyroid: not enlarged

Lymph node: not palpable

Skin pigmentation & body hair distribution: normal

Pulse: 78 b/min

BP: 120/70 mmHg

Temp:98° F

RR: 16 breaths/min

Catheter is situ

• Higher psychic function : Conscious, Oriented• Speech: Normal• Cranial nerves : Intact• Fundus: Normal• GCS: 15/15

NERVOUS SYSTEM EXAMINATION

• Wasting of lower limb muscles globally

Muscle Rt. UL Lt. UL Rt. LL Lt. LL

Bulk Normal Normal Reduced Reduced

Tone Normal Normal Decreased Decreased

Power 5/5 5/5 4/5 3/5

Involuntary movement

Absent Absent Absent Absent

MOTOR FUNCTION:

Reflex B T S K A Abd Plantar

Right ++ ++ ++ Absent

Absen

t

Present Absent

Left ++ ++ ++ Absent

Absen

t

Present

Absent

Sensory system:Pain Temp Touch Vibratio

nPosition sense

Right upper limb

All modalities of sensation was diminished at L4/L5/S1 dermatomal distribution on left side along with saddle anaestheisa

Right lower limb

Left upper limb

Left lower limb

• Sign of Meningeal irritation - Absent

• Cerebellar sign : Absent

• Gait: Antalgic gait

Musculoskeletal System

Examination of Spine: • Tenderness on percussion at level of lower lumbar

area• Restricted spinal mobility • Straight leg raising test:

limited to 40° (left side) & 90°(Right side)

Systemic examinations

Other systemic examination was normal

A 66 years old diabetic gentleman got admitted with the complaints of progressive difficulty in walking with dull aching, mild low back pain radiating to left leg, associated with retention of urine. He had anaemia, restricated spinal mobility & tenderness on lower spine. on examination of lower limbs, he had wasting, hypotonia, diminished muscle power, areflexia, absent plantar & antalgic gait. All modalities of sensation was diminished at L4/L5/S1 dermatomal distribution on left side along with saddle anaestheisa . SLR was restricted on left side. Other systemic examination was normal.

Salient feature

Provisional diagnosis

• Diabetes Mellitus Type 2• Cauda equina syndrome due to discitis

or metastasis?

Differential diagnosis

• Conus medullaris syndrome• Traumatic peripheral nerve lesions• Acute inflammatory demyelinating

polyradiculoneuropathy

Investigations

CBC:

Hb % - 8.2

WBC -6800 cu/mm

Neu-65 %

Lymph- 30%

Mono -3 %

Eosino- 1.1%

Platelet- 156000

ESR- 120mm in 1st hour

MCV: 90.3

MCH: 33.2

MCHC:36.9

PBF: Nonspecific morphology

S. Electrolytes

Na-137 mmol/l

K-4.5 mmol/lCl: 106 mmol/lHCO3: 26 mmol/lCa- 9.3 mmol/lMg- 0.9 mmol/lPhosphate-3.7

Lipid profile:

TG: 176 mg/dl

T. Chol : 164 mg/dl

LDL: 95 mg/dl

HDL:36 mg/dl

LFT:

ALT: 34 iu/L

AST: 37 iu/L

S. Total protein: 86.2

S Alb: 26.9

RFT:

S. Creatinine: 0.8mmol/l

S Urea: 29 mmol/l

HbA1c: 7.2%

Sugar - Nil

Albumin – Nil

Ketone- Nil

Epi. cell: A few /HPF

Pus cell: 1-2 /HPF

RBC: Nil

URINE R/M/E

• Blood group: AB +ve• Iron profile:

– S Iron: 7.7– TIBC: 27.2– S ferritin: 312– T sat: 28 %

Chest X-Ray

NORMAL

ECG

Normal

X ray Lumbosacral spine

• Fracture L5 Vertebrae

MRI of Lumbosacral spine

• Collapse with altered signal intensity in L5 & focal altered signal intensity in L3, S1 vertebrae

• Central & paracentral disc bulge causing thecal sac indentation & bilteral lateral recess narrowing at L5/S1 level

MRI of Lumbosacral spine

MRI of Lumbosacral spine

MRI of Lumbosacral spine

MRI of Lumbosacral spine

• Appearance: clear• Protein: 66g/L• Sugar: 4.2mmol/L( Corresponding blood

glucose-6.8 mmol/l)• Cell count: • Total WBC : Nil• Total RBC: Nil• Bacterial antigen: Negative

• USG of whole abdomen: Normal• S. PSA: 1.13• S CEA: 2.74• CA-19.9: 26.4• Alpha feto protein: Normal

• Urine for bence jones protein: Absent

X ray Skull lateral view

• Multiple lytic lesion is present

Serum protein electrophoresis

• Monoclonal band(? M protein)

CT guided FNAC

• Tissue from lumbar vertebral body L5: Multiple myeloma

Bone marrow examination

• Grossly increased plasma cells almost completely replacing normal haemopoeitic cells replacing more than 80% of eisting marrow cells. The cells are distributed in sheets & clusters & include some immature forms consistent with multiple myeloma

Bone marrow examination

Final diagnosis:

• Diabetes Mellitus Type 2• Cauda equina syndrome due to multiple myeloma

Treatment:

Short acting insulin

Daily physiotherapy

Vitamin B

Calcium

I/V Dexamethasone

Blood Transfusion

Hospital course

Patient was immediately transferred to DMCH with prior consultation to haematologist & neurosurgeon for radiotherapy, antimyeloma therapy after confirmation of diagnosis.

Follow UP

Patient was advised to follow up in Neurology after 1 month for further clinical evaluation & management.

Discussion

Case Discussion

• Multiple myeloma is a condition of malignant plasma cell proliferation derived from a single B-cell lineage 

• Making the diagnosis includes demonstrating M-proteins in either serum or urine, proving the presence of more than 10% of these malignant plasma cells in the bone marrow and observing the clinical manifestations of the disease in our patient 

• Up to 30% of patients are diagnosed incidentally while being evaluated for unrelated problems, while another third are diagnosed following a fracture .

Case Discussion

• The incidence of bone pain from osteolytic lesions ranges from 58%  to 66% of patients with myeloma

• Spinal cord compression following vertebral compression fractures or vertebral plasmacytomas comprises 5% of the presentations of multiple myeloma

• Recent articles revealed few case reports of plasmacytomas as initial presentations of multiple myeloma.

Cauda Equina Syndrome

Cauda equina syndrome refers to a characteristic pattern of neuromuscular and urogenital symptoms resulting from the simultaneous compression of multiple lumbosacral nerve roots below the level of the conus medullaris. These symptoms include low back pain, sciatica, saddle sensory disturbances, bladder and bowel dysfunction, and variable lower extremity motor and sensory loss.

Cauda Equina and Conus Medullaris Syndromes 

Etiology

• Spinal trauma including fractures• Neoplasm, including metastases• Spinal infection/abscess• Idiopathic • Spinal hemorrhage• Multiple sclerosis• Spinal arteriovenous malformations• Late-stage ankylosing spondylitis• Neurosarcoidosis

History

Patients can present with symptoms of isolated cauda equina syndrome, isolated conus medullaris syndrome, or a combination. The symptoms and signs of cauda equina syndrome tend to be mostly lower motor neuron (LMN) in nature, while those of conus medullaris syndrome are a combination of LMN and upper motor neuron (UMN) effects

History

• Low back pain• Unilateral or bilateral sciatica• Saddle and perineal hypoesthesia or anesthesia• Bowel and bladder disturbances• Lower extremity motor weakness and sensory

deficits• Retention, Difficulty initiating micturition, Decreased

urethral sensation. urinary manifestations begin with urinary retention and are later followed by an overflow urinary incontinence.

Physical examination

• Muscle strength in the lower extremities is diminished.• Sensation is decreased to pinprick and light touch in a

dermatomal pattern corresponding to the affected nerve roots.

• Vibration sense may also be affected. • Muscle stretch reflexes may be absent or diminished in

the corresponding nerve roots. • Babinski reflex is diminished or absent.• Anal sphincter tone is patulous• Muscle tone in the lower extremities is decreased, which

is consistent with an LMN lesion.

Physical Examination

Diagnostic Considerations

• AIDP• Amyotrophic lateral sclerosis• Diabetic Neuropathy• Guillain-Barré Syndrome• Multiple sclerosis• Neoplasms of Spinal Cord• Neurosarcoidosis• Spinal Cord Infections• Traumatic

Complications

• Neurogenic bladder/bowel• Erectile dysfunction• Pressure ulcers• Osteoporosis• Chronic neuropathic pain• Spasticity/contractures• Recurrent urinary tract infections• Urethral stricture• Bladder calculi• Depression

• Corticosteroids• Skeletal Muscle Relaxants• AntimyelomaTherapy• Radiotherapy• Surgery• Vertebral Augmentation• Rehabilitation• Physical therapy• Occupational therapy• Orthotic/assistive devices may be needed

 

Radiotherapy

• External beam radiation therapy represents the treatment of choice for solitary plasmacytoma of the bone

• In MM, radiation to the spine is usually employed in patients with uncontrolled pain or in case of vertebral fracture or spinal cord compression

Surgical Decompression

• In acute compression of the conus medullaris or cauda equina, surgical decompression as soon as possible becomes mandatory

• In a more chronic presentation, decompression could be performed when medically feasible and should be delayed to optimize the patient's medical condition

Morbidity is determined by the underlying etiology.The prognosis improves if a definitive cause is identified and appropriate treatment occurs early in the course.