History
Mr. Ho was a 50-year old gentleman. He was a heavy drinker. He had a history of alcohol intoxication that resulted in an emergency department admission.
He presented with a 1-year history of insidious onset glove and stocking type numbness.
The sensory symptoms were followed by a 6-month history of subacute onset gait instability, which resulted in recurrent falls.
No collateral history was available to clarify the cognitive symptoms.
Physical examination
General examination demonstrated marked disorientation.
Neurological examination was pertinent for generalized spasticity as evidenced by hypertonia, asymmetrical hyperreflexia in the upper limbs (hyporeflexia of the lower limbs), and a scissoring gait. The patient was placed on a urinary catheter due to urine retention. There was no ankle clonus.
Cerebellar signs were evident with hypometric saccades and bilateral upper limb intention tremor and dysmetria.
Investigations
A contrast MRI brain and lumbar puncture were unrevealing. Baseline bloods were normal.
Thought process
This was a syndrome of subacute onset gait disturbance with generalized upper motor neuron signs and sphincter dysfunction.
The pathology was likely localized to the cervical cord.
The etiology would commonly be structural cord compression secondary to recurrent flexion-extension neck injury in a patient with alcohol use disorder. Other considerations would include venous congestion, metabolic, neoplastic, paraneoplastic etiologies.
The presence of extra-spinal manifestations, including the cognitive impairment, glove-and-stocking type paresthesia, and cerebellar signs, may be accountable by the history of alcohol use disorder at this juncture.
Next steps
A contrast MRI spine was arranged to clarify the presence and etiology of myelopathy.