A 72-year-old man presented with subacute onset of bilateral leg weakness and urinary retention. He had a history of prostate cancer in 2013 but defaulted follow-up. On examination, he had a sensory level at T7 with reduced strength and sensation below. Imaging found extensive vertebral metastases from prostate cancer at T5-T6, causing spinal cord compression. Laboratory tests showed highly elevated PSA. The differential diagnosis included metastatic spinal cord compression versus transverse myelitis.

1. An elderly male with subacute
onset of walking difficulty &
bladder dysfunction-
Dr. W.A.P.R.S Weerarathna
Registrar WD 10/02

2. History
Mr. M, a 72 year old gentleman from
Jaffna presented to ED with the
complaints of tingling/numbness of
feet & difficulty in walking for five days
duration.
Difficulty in initiating micturition for 2
days & anuria for one day.
Experienced heaviness of legs but no
dragging of feet.

3. Mild burning pain associated with gradual
numbness of feet evolving over 5 days.
H/O BOO & intermittent LUTS prior to this
admission.
Constitutional symptoms- LOA/LOW
No H/O localized or radiating type of back
pain
No recent H/O trauma to the back or fall
from a height.
No H/O recent febrile/diarrhoeal illness

4. No associated numbness/tingling in
the hands, SOB
No haemorrhagic diathesis
No H/O chronic cough, contact H/O
PTB
No H/O bone pains, pathological
fractures
No altered bowel habits apart from
mild constipation
No history suggestive of raised ICP

5. PMH: CA Prostate in 2013-defaulted
follow-up, no H/O Diabetes, Stroke, IHD
PSH: underwent prostatectomy
DH: had been on Flutamide 250 mg tds
FH: Not significant
AH: Nill
SH: smoker-five pack years,
Ex-alcoholic, poor socioeconomic
background & insufficient knowledge
regarding his current illness.

6. Physical exam.
Conscious/rational
Not pale/icteric
BMI-22 kg/m2
Not febrile/dyspnoic
No body rashes

7. CNS
Spine/back-no
scars/deformities/tenderness
LL exam-
Inspection-no deformities/not wasted/no
fasciculations
R/S L/S
Tone increased
increased
Clonus-ankle/patellar- absent
Power prox. 3/5 3/5
distal 2/5 2/5

8. Reflexes KJ +++
+++
AJ ++
++
Plantars/Babinski up/+
up/+
Sensory system- sensory level at T7 /
pain & light touch absent below the
affected sensory level
Co-ordination-difficult to assess
JPS/vibration sense- impaired

9. UL exam- normal/ reflexes not
exaggerated
Cerebellar system- No cerebellar
signs in the UL
Fundoscopy – Normal/no papilledema.
CN exam- No focal neurological
deficites.

10. Other systemic examination
AS: No organomegaly
RS: No added sounds
CVS: BP- 130/80 mmHg, PR-88/min,
No AF, no detectable cardiac
murmers.

11. summary
A 72 year old gentleman with a H/O
CA prostate with defaulted follow-up
presented with subacute onset B/L
spastic paraparesis & urinary
retention. O/E he had sensory level at
T7 with no associated spinal deformity
or tenderness. The rest of the
systemic exam is unremarkable.

12. Differential diagnosis
Neoplastic spinal cord compression
due to metastatic prostatic
carcinoma/secondary deposits.
Acute transverse myelitis.
Spinal epidural abscess.

13. Investigations

14. CT SPINE
Extensive vertebral body
metastasis from carcinoma of
prostate.
Mild vertebral collapse &
posterior bulging of the
vertebral body at T5 & T6 levels
No significant canal narrowing.
Normal vetebral curvature
maintained.
Multiple sclerotic
metastases from carcinoma
of prostate involving
cervical/thorasic & lumber
vertebrae.

15. Pelvic bone metastsis-sclerotic/
lytic

16. USS-Abdomen
Liver- normal echogenic pattern
Kidneys-normal
Prostate-not visualized clearly
Bladder- empty,catheter bulb insitu
No abnormalities detected.

17. PSA
Total PSA > 100 ( NR 0-4 ng/dl)

18. Other basic investigations
CBC- hb-11.9 g/dl, WBC-21.9/ N-
83.6%/Hct-36/ MCV-82.7/PLT-353000
RFT- NORMAL
LFT/PT-INR-NORMAL
UFR-pro ++/ WBC- FF
S.Ca-pending

19. Discussion…….

20. Thank you!