Case Study #2 -- Bilateral Lower Extremity Paralysis

[146233]

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24 y.o. female calls 911 complaining of "falling a lot". You arrive to find her conscious/alert, reliable historian, GCS 15, stating she has been falling an increasing amount over the last two weeks. Today, she developed bilateral lower extremity paralysis, which is why she called EMS. No LOC's, no trauma, never hit her head. Hx: spinal surgery two months ago for vertebral abscess. Meds: vicodin (pt. denies taking any since last week). NDKA.

Physical exam reveals no trauma, no cyanosis, no edema, strong bilateral pedal pulses, no motor function below the hips, no pinprick sensation. [Skips a few steps.] Pt. transported to ED without incident.


What treatment would you provide? What is your diagnosis ("assessment")?

 

[viostorm]

24 y.o. female calls 911 complaining of "falling a lot". You arrive to find her conscious/alert, reliable historian, GCS 15, stating she has been falling an increasing amount over the last two weeks. Today, she developed bilateral lower extremity paralysis, which is why she called EMS. No LOC's, no trauma, never hit her head. Hx: spinal surgery two months ago for vertebral abscess. Meds: vicodin (pt. denies taking any since last week). NDKA.

Physical exam reveals no trauma, no cyanosis, no edema, strong bilateral pedal pulses, no motor function below the hips, no pinprick sensation. [Skips a few steps.] Pt. transported to ED without incident.


What treatment would you provide? What is your diagnosis ("assessment")?

Differential diagnosis:

1. Infection - perhaps TB (potts disease)
2. Malingering or Facticious disorder
3. Friedreich's Ataxia
4. Spinal cord injury
5. Spinal cord infarct (anterior spinal artery)
6. Multiple sclerosis
7. Breast cancer - metastasis through batson plexus
8. ALS (lou gerhig's disease) - shouldn't have loss of sensation
9. Myasthenia gravis - long shot because shouldn't also have loss of sensation

It would be helpful to know if it is flaccid paralysis versus spastic paralysis. also if pain and temp is intact below lesion.

I wouldn't treat without symptoms that are more suggestive. MRI 1st.

 

[146233]

It would be helpful to know if it is flaccid paralysis versus spastic paralysis. also if pain and temp is intact below lesion.

I wouldn't treat without symptoms that are more suggestive. MRI 1st.

Yes, well, this is the prehospital forum. I'm just asking for speculative diagnoses. It's flaccid paralysis, normal temp to both extremities.

 

[viostorm]

Yes, well, this is the prehospital forum. I'm just asking for speculative diagnoses. It's flaccid paralysis, normal temp to both extremities.

I guess its just you and I playing this game 🙁

So what was the diagnosis?

 

[deleted87716]

Spinal stenosis, possibly cauda equina syndrome.

Treatment? In the field? Load & go. 😉

 

[viostorm]

Spinal stenosis, possibly cauda equina syndrome.

Treatment? In the field? Load & go. 😉

I like that one too. That is why he has "attending" next to his name.

I've been too well trained by Step 1, it has thrown me off. The classic question has a "saddle shaped" deformity with bladder dysfunction. If its not classic I might as well be guessing.

 

[146233]

Attending in the ED thought he'd confirmed cauda equina syndrome (yay Kent!). Transferred to specialty care unit at another hospital. Discharged to psych with diagnosis of conversion reaction. The brain is a mysterious fig... 🙂.

And yes, as far as we're concerned on the street, it was load & go.