1) The 60-year-old male patient gradually developed weakness in his lower limbs over the past 6 months and was unable to walk for the last 3 months. He also experienced tingling, numbness and urinary incontinence. 2) On examination, he had decreased strength and sensation below thoracic vertebrae T5 with spasticity in the lower limbs. 3) Based on the history and examination findings, the provisional diagnosis was spastic paraplegia due to spinal cord compression from a tumor. Differential diagnoses included transverse myelitis, multiple sclerosis, and motor neuron disease.

1. SPASTIC PARAPLEGIA DUE TO SPINAL
CORD COMPRESSION DUE TO TUMOUR
Dr. Md. Limon Mia
Intern doctor
Jononeta Nurul Hoque Adhunik Hospital
Noakhali
Gmail:mdlimonmia1952@gmail.com

2. Particulars of the patient
• Name :Abdul Majed
• Age: 60 years
• Sex: male
• Marital status: married
• Religion: Islam
• Occupation:Rickshawpuller
• Address:East Maichara,Maijdee Sader,noakhali
• Date of admission:15 february 2019
• Date of examination: 19 february 2019

3. Chief complaints:
1.Gradual progressive weakness in both lower limbs for last 6
months.
2.Tingling sensation and numbness of both lower limbs for last
3 months .
3.Unable to walk for last three months.
4.Urinary incontinence for last 5 days.

4. History of present illness
According to the statement of the patient, he was reasonably well 6 month back.Then
he developed gradual weakness in his lower limbs initially started with the right leg then
spreads to the left leg but for the last 3 months he was bed ridden due to severe
weakness .He also complaints of tingling sensation and numbness from lower limbs
upto the mid chest.His bowel and bladder was normal but for the last 5 days he
developed urge incontinence.There is no history of weakness in upper limbs.He has no
history of weight loss,contact with smear positive TB patient .No history of bowel and
bladder surgery,no history of truma,unprotected sexual exposure ,joint deformity like
pes cavus and kyphosis.No history of fatigue, generalized weakness or exertional
dyspnea.No history of evening rise of temperature ,haemoptysis ,sweating or
cough,cold absess,back pain.No history of headache,vomiting, convulsion.

5. Continued….
No history of ,blurring of vision,tremor and ataxia,vertigo ,diplopia.there is no history of
relapsing and remitting of the disease.No history of RTI or diarrhoea,anti TB
drug,alcohol,vaccination

6. Past history
No significant past history

7. Drug history
Not remarkable

8. Personal history
He is Smoker 5 pack years,non alcoholic

9. Treatment history
Not remarkable

10. Socioeconomic history
• Lives in a building under government refugee project
• Drinks tube well water, use sanitary latrine

11. Immunization history
Immunized under EPI schedule

12. Family history
He lives with his wife.He has one daughter and one son.Both are
healthy.No othe family members are affected such type of disease

13. General examination
Apperance- anxious
Body built -average
co operation -cooperative
decubitus – lying
Intelligence-normal
Nutrition-normal
Anaemia –absent
Jaundice –absent
Cyanosis-absent
Leukonychi-absent
Koilonychia –absent
Oedema –moderate
Dehydration -absent

14. Contunied…
• Lymphnode –Inguinal group enlarged
• Thyroid gland –Normal
• Bony tenderness-absent
• Gynaecomastia –absent
• Pigmentation-absent
• Hair distribution -normal
• Blood pressor- 120/80 mmhg
• Pulse-70 bpm
• Temperature –normal
• Respiratory rate-20 bpm
• Tongue-no wasting,glossitis fasciculation or oral ulcer

15. Systemic examination

16. CNS examination
Higher psychic function
Appearence and behaviour –normal
Memory-normal
Orientation of time space and person –normal
Intelligence –normal
Speech and articulation-normal
Emotional state-normal
Level of consciousness-GCS -15/15
Hallucination and delution-absent

17. Cranial nerve examination
1.Olfactory-intact
2.Optic-visual acquity-normal
visual field-normal
colour vision-normal
Fundoscopy-not done
3.Oculumotor –ptosis squint diplopia nystagmus-absent
Ocularmovement -normal
4.Trochlear: accommodation-normal
6.Abducence –normal

18. Continued..
7.Facial
Sensory –intact,
motor-normal
8.Auditory –Rinne’s test -normal
Weber’s test-normal
Vertigo giddiness,dizziness-absent
9.Vagus –normal
10.glossopharyngeal-
Nasal voice-absent
Nasal regurgitation-absent
Gag reflex-intact
movement of palate-normal
Taste sensation-intact
Hoarseness of voice bovine cough-absent
11.Hypoglossal –tongu wasting –absent,fasciculation-absent,movement of tongue- normal
12.Spinal accessory-action of trapezius and sternocledomastoid-normal

19. upper limbs examination
Inspection-no scar, joint deformity,no muscle wasting,hair
distribution normal
Sensory –intact
Motor
Bulk -normal
Tone -normal
Power-MRC 5/5
Clonus –absent
Fasciculation-absent
Reflexes-biceps triceps supinator –normal
Superficial reflexes
Corneal reflex -normal
Patellar reflex-absent

20. lower limbs examination
Inspection-no ulcer ,scar mark ,joint deformity,swelling,no grosss
wasting no involuntary
movement(tremor,chorea,athetosis,hemiballismus)
Sensory –
Touch-absent upto thoracic five (T5)
Pain –absent upto Thoracic five (T5)
Temperature-absent upto Thoracic five( T5)
Vibration-absent
Position-absent
Tactile localization-absent
Tactile discrimination-absent
Romberg’s sign-not evaluated due to weakness of limbs
Recognitioin of size, shape, weight and form-normal

21. Continued…motor
1.Bulk –normal
2.Power –MRC 1/5
3.Tone-increased
4.Clonus-ankle clonus present but patellar clonus absent
5.Coordination –heel shin test –could not evaluated due to weakness in limbs
6.Superficial reflexes
Corneal reflex-intact
Abdominal reflex-absent
Patellerreflex -absent
Cremesteric-absent
Knee jerk-exaggerated
Ankle jerk-exaggereted
Plantar-bilaterally extensor
10.Rombergism-Not evaluated

22. Other system
Cardiovascular system –NORMAL
Gestrointestinal system –NORMAL
Respiratory system-normal
Genito urinary system-urine retention,incontinence and dribbling

23. Salient feature
Mr Abdul Maijdee 60 years old married muslim rickshawpuller normotensive non diabetic non
alcoholic smoker hailing from east maichara with the complaint of gradual weakness in lower
limbs initially started with the right leg then spread to the left leg which was initally moderate
but for the last 3 moths he was bed ridden due to severe weakness.He also complaints of
tingling sensation and numbness from lower limibs upto the mid chest.His bowel and bladder
was normal but for the last five days be developed urinary retention, loss of bladder control and
dribbling.He has no history of weight loss,contact with smear positive TB patient, evening rise of
temperature,sweating or cough. No history of bowel and bladder surgey,trauma,unprotected
sexual exposure,no history of joint deformity like pes cavus and kyphosis ,generalized weakness
fatigue .no history of high grade fever,severe bony tenderness.

24. Continued…
No h/o nystagmus or blurring of vision,tremor and ataxia,vertigo ,diplopia
dementia .there is no relapse and remission of the disease.No family history of
pernicious anaemia.There is no muscle wasting,dribbling and emotional upset.no
history of abdominal pain,melaena,abdominal distention,mass in the
abdomen.No history of vaccination, trauma, viral infection .intention
tremor,hearing loss high arched palate,palpitation,titubation
scanning,dysdiadochokinesia,dysmetria,ataxia hypotonia absent

25. On examination the patient is anxious,co-operative,decubitus is lying ,leg
odema present ,inguinal lymphnode is enlarged
Anaemia, cyanosis jaundice leukonychia koilonychia dehydration
gynaecoastia is absent.BP pulse RR temperature is within normal range.
On systemic examination of nervous system reveals higher psychic function
is normal
Cranial nerve examination is intact
Upper limbs examination is normal
Lower limbs examination reveals there is no scar mark ulcer joint swelling,no
gross wasting,hair distribution is normal,no involuntary movement

26. Continued…
There is definite sensory level .Pain touch temperature sense is lost
upto thoracic five T5 level
Bulk is normal,tone increased,power according to MRC is 1/5, ankle
Clonus is present patellar clonus is absent,knee and ankle jerk is
exaggerated.Bilateral plantar is extensor,flexion spasm present, more
prominent in right side.
Gait rombergism co ordination could not evaluated due to weakness in
limbs,
Spine examination reveals no abnormality,tenderness or deformity.

27. Provisional diagnosis
Spastic paraplegia due to spinal cord compression
due to tumour.

28. DIFFERENTIAL DIAGNOSIS
TRANSVERSE MYELITIS
MULTIPLE SCLEROSIS
MOTOR NEURON DISEASE
SUB ACUTE COMBINED DEGENERATION
FRIEDREICH’S ATAXIA

29. Investigations:
CBC
RBS
S CREATININE
SPUTUM FOR AFB
MT
VDRL
MRI OF DORSOLUBER SPINE
CXR P/A VIEW
URINE FOR BENZ ZONE PROTEIN
SERUM VIT B12 ASSAY
CSF STUDY

30. Management of the patients:
Conservative management
MEDICAL MANAGEMENT:
Surgical Treatment

31. KNOWLEDGE IS POWER
THANK YOU