Longitudinal spinal cord lesion

Case #83: MRI T-spine, 1/5/93: A single elongated demyelinating lesion in the upper thoracic spine.

CC: Paresthesias from the mid-thorax caudally to the feet.

Hx: This 45y/o RHF began experiencing dysesthesias about the mid-thorax and paresthesias from the mid-thorax down to her feet (worse on left than right) on 12/20/92. In addition, she simultaneously developed progressive bilateral lower extremity weakness and has not been able to ambulate since 12/30/92. She was admitted to a local hospital on 12/30/92 and was treated with IV Solu-Medrol for three days, and then released on prednisone taper. She reports that her symptoms have not improved since discharge and her dysesthesias have worsened.

She was diagnosed with possible demyelinating disease in 1984 when she presented with LLE clumsiness, and paresthesias in both hands, the right elbow and right face. Workup at that time revealed elevated CSF IgG level and IgG synthesis index. CSF was acellular and cultures were unremarkable. ESR, TFT's, ANA, SPEP, VDRL and urine heavy metal screen were negative. HCT unremarkable. Her symptoms completely resolved within 2 months. Brain MRI revealed two areas of increased signal in the right frontal region on T2 images.

In 2/90, she developed paresthesias in the RLE, difficulty with balance, and weakness in BUE and BLE (right > left). She was evaluated in California and an MRI was obtained. The results are unknown.

By 5/91, she resigned from teaching due to worsening lower extremity weakness. The weakness stabilized until 12/20/92.

MEDS: Prednisone taper, Tylenol #3 for dysesthesias.

PMH: 1) Nocturnal seizure disorder diagnosed at age 6. Treated with PB until age 22. No spells since. 2)demyelinating disease.

FHx: Mother with Alzheimer's disease. No family hx of MS.

SHx: Algebra teacher until 5/91. Denied ETOH, Tobacco, or illicit drug use. Lives with husband.

EXAM: BP102/65 HR68 RR20 37.5C

MS: A & O to person, place, and time. Speech fluent and without dysarthria.

Motor: BUE 5/5. HF2+/2 KE 3-/3- KF 2+/2+ AF 2/2 AE 4/4

Sensory: Hyperesthetic T5-T10 (L > R). Decreased PP and LT throughout entire left side below T10. Vib/Prop intact throughout.

Coord: mild dysmetria and dysdiadochokinesis (R>L).

Station/Gait: ND

Reflexes: 3/3 throughout. No clonus. Babinski signs present bilaterally.

COURSE: CBC normal except WBC 17.1 k/mm3; no left shift. GS, PT, PTT, UA were unremarkable. MRI of the thoracic spine revealed an intramedullary thin linear area of increased T2 signal within upper thoracic spinal cord spanning 2 vertebrae. MRI Brain and C-Spine revealed multiple foci of high signal on T2 and Proton Density weighted images in the deep white matter and peritrigonal regions, right pons, and cervical cord. . She was treated with a 5 day course of IV Methylprednisolone followed by a prednisone taper. She then underwent physical therapy. The Tylenol #3 was discontinued and her pain was relieved with Carbamazepine 200mg TID. Baclofen 10mg QID relieved much of her spasticity, and Ditropan was started for urinary frequency.