Case History #32

Date of Admission: 4-15-1976

HISTORY OF PRESENT ILLNESS:

This 54-year-old right-handed white male retired postal worker was admitted to the hospital for evaluation of fecal incontinence and urinary incontinence.  Approximately 4 to 5 months prior to admission, the patient noted the gradual onset of fecal incontinence and also episodes of urinary incontinence.  These episodes apparently came on fairly suddenly without any conscious awareness that they were about to occur.  These symptoms remained present up to the time of admission and may have been somewhat progressive.  On 3-24-76, the patient was admitted to the Neurosurgery Service, and a complete myelogram on that day showed no evidence of obstruction or spinal cord tumor.  Asymmetric filling defects in the midcervical region were noted and were felt to be due to mild cervical spondylosis.  During that hospitalization, urology consultation was obtained, and a cystometrogram was attempted but could not be completed.  However, the diagnosis of “probable neurogenic bladder” was offered by the consultant.

PAST NEUROLOGICAL HISTORY:

In April 1971, the patient underwent coronary artery bypass surgery for angina pectoris.  When he awoke from the anesthesia, he noted the inability to move his left upper extremity and his right lower extremity.  He noted no difficulty whatsoever with the right upper extremity and the left lower extremity.  These symptoms gradually improved, and with rehabilitation he obtained an almost complete recovery.  Upon close questioning, the patient indicated that he may have had difficulty with fecal and urinary incontinence after this cardiac surgery in 1971, but that the symptoms had definitely increased over the past 4 to 5 months.

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact.

Cranial Nerves:  Cranial nerve examination was entirely normal.

Motor System:  There were no areas of focal muscular atrophy.  There were no fasciculations.  Muscle tone was normal in all 4 limbs.  Muscle power was normal (5/5) throughout except for a mild weakness (4+/5) of the left elbow extensors and a moderate weakness (3/5) of the right ankle dorsiflexors. 

Reflexes:  Deep tendon reflexes were 2/4 in the right upper extremity and left lower extremity.  In the left upper extremity, deep tendon reflexes were brisk and rated at 3/4.  In the right lower extremity, deep tendon reflexes were 4/4 with sustained clonus at the right ankle.  Plantar reflexes were flexor on the left and extensor on the right. 

Sensory System:  Intact to all modalities, including cortical sensations, in all 4 limbs.

Cerebellar Function:  Intact.

Gait and Stance:  Regular gait was performed normally except for circumduction of the right lower extremity and a mild foot drop (i.e., weakness of the ankle dorsiflexors) on the right.  Tandem gait was performed normally, and the Romberg test was negative.

Questions:

1.  Are the findings in the left upper limb and right lower limb suggestive of an upper motor neuron or lower motor neuron process?

2.  If all signs and symptoms in this case are due to a single localized lesion, there is only one place in the central nervous system that this lesion can be placed.  Where is that location, at what level in the central nervous system is it, and what structures are involved by the pathologic process?

3.  The clinical findings in this case represent a rare but classic neurologic syndrome.  What is the name of this syndrome? 

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

5.  What diagnostic procedure(s) would you undertake at this point?