A 57-year-old man comes to the office due to several months of progressive difficulty walking. Lately, weakness and stiffness in both legs has made it difficult to ambulate without support. The patient also has numbness and tingling in his arms and legs. His medical history includes hypertension and hyperlipidemia. The patient has smoked a pack of cigarettes daily for 30 years and has used injection drugs in the past. He has had several sexual partners. Temperature is 36.6 C (97.9 F), blood pressure is 140/90 mm Hg, and pulse is 78/min. Physical examination shows normal mental status and cranial nerves. There is mild weakness and atrophy of the upper arm muscles with decreased triceps reflex. Bilateral lower extremity strength is 4/5. Vibratory and pain sensation is decreased in both the hands and legs. Babinski sign is upgoing bilaterally. Further evaluation of this patient is most likely to reveal which of the following?

Question

A 57-year-old man comes to the office due to several months of progressive difficulty walking.  Lately, weakness and stiffness in both legs has made it difficult to ambulate without support.  The patient also has numbness and tingling in his arms and legs.  His medical history includes hypertension and hyperlipidemia.  The patient has smoked a pack of cigarettes daily for 30 years and has used injection drugs in the past.  He has had several sexual partners.  Temperature is 36.6 C (97.9 F), blood pressure is 140/90 mm Hg, and pulse is 78/min.  Physical examination shows normal mental status and cranial nerves.  There is mild weakness and atrophy of the upper arm muscles with decreased triceps reflex.  Bilateral lower extremity strength is 4/5.  Vibratory and pain sensation is decreased in both the hands and legs.  Babinski sign is upgoing bilaterally.  Further evaluation of this patient is most likely to reveal which of the following?

Quizplus · Accepted Answer

11ec25c8_d59d_383a_bc81_c34943863694_MD0003_00 This middle-aged patient with progressive ambulation difficulties and extremity weakness has neurologic findings suggestive of cervical myelopathy. The most common cause of cervical myelopathy in older adults is spondylosis, a degenerative spine disease that can narrow the cervical spinal canal and compress the spinal cord. Patients usually develop slowly progressive gait dysfunction, extremity weakness, and vibratory/pain sensation changes. Neurologic examination typically shows lower motor neuron (LMN) signs such as weakness and atrophy at the level of the lesion (in the arms) and upper motor neuron (UMN) signs such as hyperreflexia below the level of the lesion (in the legs). This distribution of LMN and UMN signs should raise suspicion for cervical myelopathy. Spondylosis of the cervical spine is often diagnosed radiographically, and myelopathy is confirmed with MRI or CT myelogram. Patients may require surgical decompression. (Choice B) An elevated protein level with normal cell count on cerebrospinal fluid analysis can be seen in acute inflammatory demyelinating polyneuropathy, a postinfectious peripheral neuropathy that causes ascending paralysis and areflexia. UMN findings are atypical. (Choice C) An epidural fluid collection can compress the spinal cord but is usually associated with fever. Muscle atrophy, a sign of a chronic process, would be unusual. (Choice D) A parasagittal meningioma can compress the motor strip in the brain and cause lower extremity weakness with UMN and not LMN findings. (Choice E) Syringomyelia and spondylosis can result in similar manifestations. However, patients with syringomyelia often have loss of pain and temperature sensation in a "cape-like" distribution over the shoulders, back, and arms. In addition, syringomyelia is far less common than spondylosis. Educational objective: The most common cause of cervical myelopathy in older adults is spondylosis, a degenerative spine disease that causes canal narrowing with spinal cord compression. Manifestations include progressive gait instability and weakness in the extremities. Examination usually shows lower motor neuron signs at the level of the lesion (arms) and upper neuron signs below the level of the lesion (legs). References: Differential diagnosis for cervical spondylotic myelopathy: literature review. (http://www.ncbi.nlm.nih.gov/pubmed/23962997) Cervical spondylotic myelopathy. (http://www.ncbi.nlm.nih.gov/pubmed/20445427)

A 57-Year-Old Man Comes to the Office Due to Several