A 44-Year-Old Man With Progressive Weakness and Back Pain

Benjamin O. Cornwell, DO; Jignesh Modi, MD

Disclosures

November 26, 2018

Physical Examination and Workup

Upon physical examination, his oral temperature is 98.6°F (37°C). His pulse has a regular rhythm, with a rate of 68 beats/min. His blood pressure is 123/89 mm Hg. He is awake, alert, and oriented to time, person, place, and situation.

The cranial nerves II-XII are grossly intact, and the patient's pupils are 3 mm and reactive to 2 mm. His extraocular movements are intact. Face, tongue, uvula, and shoulder shrug are symmetric. The motor examination of the lower extremities reveals 5/5 strength in his bilateral hip flexors and knee extensors. He has 4/5 strength with right dorsal and plantar flexion and 5/5 strength with left dorsal and plantar flexion.

Sensory examination reveals intact sensation to vibration, but he has reduced pinprick sensation from the midcalf and below bilaterally. Deep tendon reflexes are 1-2+, with absent bilateral ankle clonus. He has an equivocal left Babinski response with downgoing toes on the right. The patient's gait is normal.

MRI with and without contrast of the thoracic and lumbar spine is performed and reveals a posterior epidural mass involving the T12-L1 level (Figures 1-3).

Figure 1.

Figure 2.

Figure 3.

Signal characteristics of the mass include homogeneous isointense signal intensity on T1, homogeneous high signal on T2, and uniform homogeneous postcontrast enhancement. Associated mass effect is noted on the dorsal aspect of the spinal cord without signal changes within the cord to suggest edema or myelomalacia. The mass does not extend into the adjacent neuroforamina nor does it involve the osseous structures and the adjacent intervertebral disks, which have normal signal and appearance. The paraspinal musculature and soft tissues have a normal appearance. The visualized portions of the thorax and abdomen are unremarkable. Laboratory analysis findings, including a complete blood count and a basic metabolic panel, are normal.

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