Author: Kevin Connolly, DO
Co Author #1: Kevin Connolly, DO
Co Author #2: Elizabeth Rothe, MD
Co Author #3: Frank Willard, PhD
Senior Editor: Kristine Karlson, MD, FAMSSM
Editor: Laura Goldberg, MD

Patient Presentation:
A 61 year old white male presented to the emergency department (ED) several times over 2 days with acute onset and progressive pain, upper extremity (UE) numbness, and lower extremity (LE) weakness that eventually lead to complete right leg paralysis.

History:
Patient suddenly developed pain after getting up from a chair that evolved over several hours. He reported pain in his neck radiating to his upper back/chest, and shoulders, with numbness extending down the ulnar side of the arms to his pinky fingers and right lower extremity (RLE). Earlier, he endorsed hand clumsiness while brushing his teeth but was ambulating without difficulty. On initial work-up, he had normal vital signs, decreased right hip strength, but otherwise a normal physical exam. Electrocardiogram (EKG), chest X-ray (CXR), computed tomography angiogram (CTA) of the chest were all negative, magnetic resonance imaging (MRI) of the cervical-spine (C-spine) did not have any new findings. He was diagnosed with cervical radiculopathy, atypical chest pain, and was discharged home with steroids and instructions for follow-up with spine surgery. He returned to the ED the next day with worsening numbness that spread to his abdomen, genital anesthesia, weakness in his upper extremities, and paralysis of his right leg.

Past medical history: Traumatic falls from paragliding and rock climbing resulting in compression fractures at T10 & L1; severe cervical and thoracic spondylosis; arthrogenic low back pain; transient right LE weakness leading to frequent falls; remote Lyme disease; pneumothorax; post-traumatic stress disorder; dissociative identity disorder; panic disorder; amnesia from mild head injury
Past surgical history: Right knee anterior cruciate ligament (ACL) repair, left knee chondroplasty, lumbar discectomy in 1986
Social history: Former smoker, denied alcohol use, worked as a computer analyst and now a yoga instructor, lives a healthy lifestyle

Physical Exam:
Vitals: Temperature 97.5 F, heart rate 56, orthostatic blood pressure 104/62-88/64, respiratory rate 16, SpO2 100% on room air
General: No acute distress
Head, ears, eyes, nose, throat, cardiovascular, respiratory, chest, and gastrointestinal: Unremarkable
Genitourinary: Loss of urethral sensation, urinary retention, bowel incontinence with absent sphincter tone
Neuro:
Motor: Right LE complete flaccid paralysis, left LE 3-4/5 strength in all motions. Tone normal and no clonus in bilateral (b/l) LEs. Right and left UEs 4/5 strength to finger flexion and abduction/adduction; other motions of UEs 5/5 strength. Tone was normal and no clonus in b/l UEs
Sensation: Loss of pain sensation to pinprick from C7 to S1 dermatomes b/l. Vibratory/tactile sensation intact throughout
Reflexes: Patellar and Achilles deep tendon reflexes (DTRs) 0/4 b/l. Right triceps DTR 1/4, all other DTRs in the UEs were 0/4 (b/l biceps and brachioradialis were present the next day)
Cranial nerves (CN) II-XII: Intact
Cerebellar: Finger to nose and pronator drift were unremarkable
Kernig, and Brudzinski signs: Absent

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