A 77-year-old man comes to the office with his wif - seaside

[ArchivalUser]

A 77-year-old man comes to the office with his wife because of "walking difficulties." He says that over the past 5 months he has noticed that when he walks or stands for longer than 15 minutes he gets pain and weakness in his thighs. The pain is usually relieved by sitting. Within the past 1-2 years he began to get a "discomfort" in the anterolateral thighs, more in the right lower extremity than the left. He also gets a pain in his right hip, which radiates down to just below his knee. He denies ever having any calf pain. He urinates 2-3 times per night and will lose 1 or 2 drops of urine if he cannot make it to the bathroom in time. His wife has notice that he has a tendency to stand with his knees slightly bent rather than straight legged. He tells you that 16 years ago he began to feel "unsteady on his feet." He did not fall or experience pain at that time, but he had "pins and needles feelings" in his fingers and feet and "lost the feeling of his feet being attached to the ground." He saw 2 different doctors at that time, had a myelogram, and was diagnosed with C4-5 damage. He underwent C4-5 intercervical discectomy and osteophyte removal. After the surgery he wore a neck brace for several months and the symptoms remained stable. He noticed that his knee reflexes were stronger after the surgery. 4-5 years ago he began to notice that his right knee would buckle. This resulted in 2-3 falls over a 1-year period. He saw a neurologist who prescribed physical therapy and a cervical collar to be worn at night. He did well and stopped wearing the collar about 1 year ago. Physical examination shows weak, but palpable distal pulses, moderately limited neck range of motion, mild weakness of the deltoids and biceps bilaterally, mild weakness of hamstrings and extensor hallucis longus bilaterally, and a normal sensory exam. He has brisk symmetric deep tendon reflexes and down-going toes bilaterally. Tests of coordination are normal and his gait is normo-based and steady but mildly spastic. Cranial nerve and mental status examinations are unremarkable. The most appropriate next step is to
A. order an MRI of the brain
B. order an MRI of the cervical spine
C. order an MRI of the lumbar spine
D. perform electromyography and nerve conduction study
E. send him for an angiogram of the lower extremities

[ArchivalUser]

cc

[ArchivalUser]

C

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ccc

[ArchivalUser]

BBB

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BB

[ArchivalUser]

Lumbar spinal stenosis

[ArchivalUser]

Explanation:

The correct answer is C. The history is typical of that for neurogenic claudication, which is caused by lumbar stenosis. The lower extremity weakness is also typical of bilateral L4/L5 radiculopathies. You would want to do an MRI to confirm the diagnosis and make sure that other pathology such as a spinal tumor was not responsible.

[ArchivalUser]

His gait disorder is being caused primarily by pain, which is secondary to neurogenic claudication of the lumbar spine. He has known cervical spine problems, which may be contributing by impairing balance. It would also cause weakness of deltoids and biceps by C5 root compression. He may need a cervical spine MRI (choice B) at some point, but it is not primarily causing his walking troubles.