# Clinical Cases: Spinal Cord Disorders

## Case 1: Acute Spinal Cord Compression from Metastatic Disease

### Patient Demographics
- **Age:** 67 years
- **Sex:** Male
- **Occupation:** Retired construction foreman

### Chief Complaint
"I can't walk and I'm having trouble urinating."

### History of Present Illness
The patient presents to the emergency department with progressive weakness in both legs over 5 days and new-onset urinary retention. He has had mid-back pain for 6 weeks, which he attributed to "old age" and prior work injuries. The back pain is constant, worse at night when lying down (red flag), and not relieved by rest. Over the past week, he noticed his legs felt "heavy" and he was stumbling. Yesterday, he could barely walk and needed his wife's help to get to the bathroom. This morning, he was unable to urinate despite feeling the urge. He has also noticed numbness from his belly button down. He has a history of prostate cancer diagnosed 4 years ago, treated with radical prostatectomy and radiation, with rising PSA over the past 6 months (not yet worked up).

### Neurological Examination Findings

**Mental Status:**
- Alert, oriented, anxious
- GCS: 15

**Cranial Nerves:**
- Intact II-XII

**Motor Examination:**
| Muscle Group | Right | Left |
|--------------|-------|------|
| Hip flexion (L1-L2) | 3/5 | 3/5 |
| Knee extension (L3-L4) | 3/5 | 2/5 |
| Ankle dorsiflexion (L4-L5) | 2/5 | 2/5 |
| Ankle plantarflexion (S1-S2) | 2/5 | 1/5 |
| Toe extension (L5) | 1/5 | 1/5 |
- Upper extremities: 5/5 throughout
- **Increased tone in both legs** (spasticity)

**Sensory Examination:**
- **Sensory level at T10** - decreased sensation below umbilicus
- All modalities affected (light touch, pinprick, temperature)
- Decreased proprioception in both feet
- Saddle area: Decreased sensation

**Reflexes:**
- Upper extremities: 2+
- **Patellar: 4+ bilateral (hyperreflexia)**
- **Achilles: 4+ bilateral**
- **Bilateral Babinski signs: Extensor** (upgoing toes)
- Clonus at ankles (>5 beats)
- **Absent bulbocavernosus reflex** (sacral dysfunction)

**Rectal Examination:**
- Decreased anal sphincter tone
- Absent voluntary contraction
- Diminished perianal sensation

**Bladder:**
- Bladder scan: 800 mL residual (urinary retention)

### Localization
- Spinal cord lesion at approximately T10 level
- Upper motor neuron pattern in legs (hyperreflexia, Babinski, spasticity)
- Bladder and bowel dysfunction (conus involvement or bilateral cord compression)
- Sensory level at T10

### Neuro Workup - URGENT

**MRI Entire Spine with Contrast (EMERGENT):**
- **T9-T10: Pathological compression fracture of T9 vertebral body**
- Epidural soft tissue mass extending posteriorly from T9 vertebra
- **Severe spinal cord compression with cord signal change** (T2 hyperintensity)
- Additional lesions at T4, L2 vertebral bodies (no cord compression)
- Findings consistent with metastatic disease

**CT Chest/Abdomen/Pelvis:**
- Sclerotic bone lesions throughout axial skeleton
- Enlarged pelvic lymph nodes
- Consistent with metastatic prostate cancer

**Laboratory Studies:**
- PSA: 285 ng/mL (markedly elevated)
- Alkaline phosphatase: 342 U/L (elevated - bone involvement)
- CBC, CMP: Normal
- Coagulation: Normal

### Diagnosis
**Metastatic Epidural Spinal Cord Compression (MESCC)** from prostate adenocarcinoma

### Management - NEUROLOGICAL EMERGENCY

**Immediate Interventions (within 1 hour of presentation):**

1. **High-dose Dexamethasone:**
   - 10 mg IV bolus immediately
   - Followed by 4 mg IV every 6 hours
   - Reduces peritumoral edema

2. **Urgent Consultations:**
   - Neurosurgery: For surgical decompression consideration
   - Radiation Oncology: For emergent radiation therapy
   - Medical Oncology: For systemic therapy planning

3. **Bladder Care:**
   - Foley catheter placement for urinary retention
   - Monitor output

**Treatment Decision:**
- Given moderate neurological deficits (still ambulatory with assistance), both surgery and radiation are options
- **Decision: Surgical decompression followed by radiation therapy**
  - Surgery indicated because: Unknown histology (though likely known prostate), moderate deficits, single level of symptomatic compression, good performance status

**Surgical Treatment:**
- **T9 corpectomy with anterior reconstruction**
- Posterior decompressive laminectomy T8-T10
- Pedicle screw fixation T7-T11 for stabilization
- Histopathology: Metastatic prostatic adenocarcinoma

**Post-operative Radiation:**
- External beam radiation therapy: 30 Gy in 10 fractions to T9 region
- Started 2 weeks post-operatively after wound healing

**Systemic Therapy:**
- Androgen deprivation therapy (ADT): Leuprolide + abiraterone
- Bone-targeting agent: Denosumab or zoledronic acid

**Rehabilitation:**
- Acute inpatient rehabilitation
- Physical therapy: Strengthening, mobility training
- Occupational therapy: ADL training
- Bladder training (intermittent catheterization vs indwelling)
- Bowel program

### Outcome
- Post-operative improvement in leg strength (4/5 bilateral)
- Resumed ambulation with walker at 2 weeks
- Urinary function: Intermittent self-catheterization
- Continued systemic therapy with good PSA response

### Clinical Image
![Spinal Cord Compression MRI](case_01_image.jpg)

**Image Description:** Sagittal MRI of the thoracic spine showing vertebral body collapse with epidural extension causing severe spinal cord compression and cord signal abnormality (T2 hyperintensity indicating cord edema/injury).

**Attribution:** Image from Wikimedia Commons. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:SCIWORA_MRI.jpg

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## Case 2: Cauda Equina Syndrome

### Patient Demographics
- **Age:** 45 years
- **Sex:** Female
- **Occupation:** Nurse

### Chief Complaint
"I can't feel when I need to pee and my legs are weak."

### History of Present Illness
The patient, a nurse with a 10-year history of chronic low back pain and known L4-L5 disc herniation, presents with acute worsening of symptoms over 48 hours. Three days ago, she had sudden onset of severe low back pain radiating down both legs while lifting a patient at work. Over the past 2 days, she has developed progressive weakness in both legs, difficulty walking, and numbness in her buttocks and inner thighs. Most concerning, she noticed yesterday that she could not feel when her bladder was full - she had an episode of urinary incontinence without awareness. She also has not had a bowel movement in 3 days and has difficulty initiating urination. She denies any trauma, fever, or weight loss. She has tried over-the-counter NSAIDs without relief.

### Neurological Examination Findings

**Mental Status:**
- Alert, oriented, in significant distress from pain

**Motor Examination:**
| Muscle Group | Right | Left |
|--------------|-------|------|
| Hip flexion (L1-L2) | 4/5 | 4/5 |
| Knee extension (L3-L4) | 4/5 | 4/5 |
| Ankle dorsiflexion (L4-L5) | 3/5 | 2/5 |
| Great toe extension (L5) | 2/5 | 2/5 |
| Ankle plantarflexion (S1-S2) | 3/5 | 3/5 |
- Upper extremities: 5/5

**Sensory Examination:**
- **Saddle anesthesia**: Decreased sensation over perineum, perianal region, posterior thighs bilaterally (S2-S5 distribution)
- Decreased sensation: L4-S1 dermatomes bilateral lower extremities
- Proprioception intact

**Reflexes:**
- Upper extremities: 2+
- Patellar: 1+ bilateral (diminished - L3-L4)
- **Achilles: Absent bilateral** (S1-S2)
- **Plantar responses: Absent** (cannot elicit)
- **Bulbocavernosus reflex: Absent**
- Anal wink: Absent

**Rectal Examination:**
- **Decreased anal sphincter tone**
- **Absent voluntary anal contraction**
- Decreased perianal sensation (S2-S4)

**Bladder:**
- Bladder scan: 650 mL (significant retention)
- Unable to void

### Red Flags Present - Cauda Equina Syndrome
1. **Bilateral leg weakness** - motor involvement
2. **Saddle anesthesia** - sensory loss in perineal region
3. **Urinary retention with overflow incontinence** - bladder dysfunction
4. **Fecal incontinence/constipation** - bowel dysfunction
5. **Absent bulbocavernosus reflex** - sacral arc dysfunction
6. **Bilateral lower extremity symptoms**

### Neuro Workup - EMERGENT

**MRI Lumbar Spine without and with Contrast (STAT):**
- **Large central disc herniation at L4-L5** (14mm posterior protrusion)
- Severe compression and displacement of the cauda equina nerve roots
- Nerve roots pushed posteriorly and laterally
- No enhancement to suggest tumor or infection
- Mild degenerative changes at L3-L4 and L5-S1 without significant compression

**Laboratory Studies:**
- CBC, CMP, coagulation: Normal
- ESR, CRP: Normal (arguing against infection)

### Diagnosis
**Cauda Equina Syndrome** secondary to L4-L5 disc herniation

### Management - SURGICAL EMERGENCY

**Immediate Steps:**
1. **Foley catheter** - decompress bladder
2. **NPO status** - preparation for surgery
3. **IV access, labs, type and screen**
4. **STAT neurosurgery consultation**

**Surgical Treatment:**
- **Emergent L4-L5 laminectomy and discectomy**
- Surgery performed within 12 hours of presentation
- Decompression of cauda equina achieved
- Large disc fragment removed

**Intraoperative Findings:**
- Large central disc extrusion compressing thecal sac
- Cauda equina nerve roots severely compressed but intact
- Good decompression achieved

**Post-operative Care:**
- Neurological monitoring every 4 hours
- Continued Foley catheter
- DVT prophylaxis
- Pain management
- Physical therapy on post-op day 1

### Post-operative Course and Prognosis

**Immediate Post-op:**
- Pain significantly improved
- Motor function: Gradual improvement over weeks
- Sensory: Saddle sensation slowly returning

**At 6 Weeks:**
- Ambulating independently
- Lower extremity strength 4+/5 bilateral
- Some residual sensory deficit in S1 distribution

**Bladder Function:**
- Initially required intermittent catheterization
- By 3 months: Able to void spontaneously but with incomplete emptying
- Urology follow-up for long-term management

**Bowel Function:**
- Improved with bowel regimen
- Occasional urgency but no incontinence

### Prognostic Factors
1. **Time to surgery**: Most critical factor - surgery within 24-48 hours optimal
2. **Severity of deficits at presentation**: Complete deficits = worse prognosis
3. **Duration of symptoms before surgery**: Shorter = better
4. **Bladder dysfunction**: Often slowest to recover, may be permanent
5. **This patient**: Incomplete syndrome, surgery within 12 hours - favorable

### Clinical Image
![Cauda Equina MRI](case_02_image.jpg)

**Image Description:** Sagittal MRI of the lumbar spine showing a large central disc herniation at L4-L5 causing severe compression of the cauda equina nerve roots within the thecal sac.

**Attribution:** Image from Wikimedia Commons. Public domain. Source: https://commons.wikimedia.org/wiki/File:CaudaEquinaMRI.jpg

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## Key Teaching Points

### Metastatic Spinal Cord Compression
1. **Back pain is the earliest symptom** - often precedes neurological deficits by weeks
2. Red flags: Pain worse at night, pain with recumbency, known cancer history
3. **MRI entire spine** - multiple levels common
4. **Dexamethasone immediately** - do not wait for imaging
5. Surgery vs radiation depends on: Tumor type, stability, single vs multiple levels, deficit severity
6. **Ambulatory status at treatment = ambulatory outcome** - time is critical

### Cauda Equina Syndrome
1. **Surgical emergency** - decompress within 24-48 hours
2. Cardinal features: Saddle anesthesia, urinary retention, bilateral leg weakness
3. Cauda equina = LMN lesion (hyporeflexia, flaccid) vs cord = UMN (hyperreflexia, spastic)
4. Most common cause: Large central disc herniation
5. **Bladder function** often last to recover, may be permanently impaired
6. Always check: Post-void residual, rectal tone, perianal sensation, bulbocavernosus reflex