Case History #171

Date of Consultation: 2-22-1990

This 39-year-old right-handed white female administrative assistant was referred for neurologic evaluation of left lower limb numbness.  Six days prior to consultation (2-16-90), the patient was drying herself after a shower and noted that the sensation in her left calf felt unusual to her.  The next morning (2-17-90), she awoke and noted the entire left lower limb was numb and somewhat tingly.  By the following day (2-18-90), this area of numbness and tingling had ascended to about the left T6 level and seemed to form a sensory level at that point.  Below the T6 level on the left, she experienced numbness, tingling, alternating hot and cold sensations, an itching feeling, and an intermittent aching.  This numbness involved both the left side of the rectum and perineum.  For the past 3 days she noted no significant change in her symptoms, neither improvement nor progression.

Associated with these sensory symptoms, she denied any other neurologic signs or symptoms.  She had no bowel or bladder incontinence or retention.  She also denied any sharp, shooting, radicular pain, either from the low back region into the left lower limb or from the thoracic region around the circumference of the trunk.  She did not notice that her symptoms worsened with overheating or a hot shower.  She experienced nothing reminiscent of a Lhermitte’s sign.

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact.

Cranial Nerves:  Sensation of smell was intact bilaterally.  Visual acuity was J1 O.U. with her glasses.  Visual field and funduscopic examinations were unremarkable.  External ocular movements were full without nystagmus or diplopia.  Pupils were equal, round, and reactive to light and accommodation.  Sensory and motor functions of the Vth cranial nerve were normal.  There was no facial weakness.  Hearing was intact bilaterally.  XIth cranial nerve functions were normal.  Tongue and palate appeared normal. 

Motor System:  There was no evidence of focal or generalized muscular atrophy.  There were no fasciculations.  Muscle tone and power were normal in all 4 limbs. 

Reflexes:  Deep tendon reflexes were perhaps slightly brisker in the right upper limb than the left, but were equal and symmetric in the lower limbs.  Plantar reflexes were flexor bilaterally. 

Sensory System:  All modalities of sensation, including cortical sensations, were normal, except for the following.  There was decreased appreciation of pinprick in the entire left lower limb and on the left side of the trunk up to a sensory level at about T6.  There was some hyperpathic quality to stimulation in the involved area, but this was mild. 

Cerebellar Function:  The patient performed all cerebellar tests normally. 

Gait and Stance:  Regular and tandem gait were performed normally, and the Romberg test was negative.

Questions

1.  Considering this patient’s history and physical examination, how precisely can the neurologic lesion be localized in this case? 
           

2.  Is there evidence of peripheral nervous system involvement in this case, and, if so, what is the level (s) of the involvement?  Is there evidence of spinal cord involvement in this case and, if so, at what level?

3.  Indicate the level of the neurologic lesion in this case as precisely as possible and the structures involved by the pathologic process.  What side of the nervous system was involved?
          

Signs or Symptoms                           Site of Lesion            Localization          
Left sensory level at T6,
which involved the pain
pathways on examination

Subtle increased DTRs
in the RUE 

4.  In general, what type of pathologic process do you think is involved in this case?