Elderly male with Flaccid paraparesis diagnosed as Cauda Equina Syndrome due to Multiple Myeloma

1. Dr. Md Rashedul Islam
FCPS, MRCP(UK)
Registrar, Neurology, BIRDEM

2. A 66 years old diabetic, right handed, gentleman,
hailing from Keraniganj, Dhaka got admitted in BIRDEM
General Hospital on 12th February,15 with the
complaints of-
• Difficulty in walking for 1 month
• Retention of urine for 2 days

3. According to the statement of the patient, he
was reasonably well 1 month back. Then he
developed difficulty in walking which was
gradual on onset associated with low back
pain. His back pain was dull aching in nature,
mild in severity with radiation to left lower
limb, aggravated by walking, movement,
change of posture relieved by taking rest. It
was not associated with fever, cough, weight
loss, alternation of bowel habit, h/o trauma.

4. H/O Present illness
He also had complaints retention of urine which
was sudden on onset associated with abdominal
discomfort. He was catheterized outside
BIRDEM. He didn’t have complaints of urgency,
hesitancy, frequency of micturation.

5. H/O past illness:
Nothing contributory
Socioeconomic history:
He belongs to a middle class family
Personal history:
He is non alcoholic, non smoker

6. Family history:
Nothing significant
Treatment history:
Insulin
Tab. Vit B complex

7. General examination:
Appearance: ill looking, anxious
Built: average
Decubitus: on choice
Anaemia ++
Jaundice
Cyanosis
Oedema
Dehydration
Clubbing
Koilonychia
Leukonychia
Absent

8. General examination:
Neck vein: not engorged
Thyroid: not enlarged
Lymph node: not palpable
Skin pigmentation & body hair distribution: normal
Pulse: 78 b/min
BP: 120/70 mmHg
Temp:98° F
RR: 16 breaths/min
Catheter is situ

9. • Higher psychic function : Conscious, Oriented
• Speech: Normal
• Cranial nerves : Intact
• Fundus: Normal
• GCS: 15/15
NERVOUS SYSTEM EXAMINATION

10. • Wasting of lower limb muscles globally

11. Muscle Rt. UL Lt. UL Rt. LL Lt. LL
Bulk Normal Normal Reduced Reduced
Tone Normal Normal Decreased Decreased
Power 5/5 5/5 4/5 3/5
Involuntary
movement
Absent Absent Absent Absent
MOTOR FUNCTION:

12. Reflex B T S K A Abd Plantar
Right ++ ++ ++ Abse
nt
Ab
sen
t
Present Absent
Left ++ ++ ++ Abse
nt
Ab
sen
t
Present
Absent

13. Sensory system:
Pain Temp Touch Vibratio
n
Position
sense
Right upper
limb
All modalities of sensation was diminished
at L4/L5/S1 dermatomal distribution on
left side along with saddle anaestheisa
Right lower
limb
Left upper
limb
Left lower
limb

14. • Sign of Meningeal irritation - Absent
• Cerebellar sign : Absent
• Gait: Antalgic gait

15. Musculoskeletal System
Examination of Spine:
• Tenderness on percussion at level of lower lumbar
area
• Restricted spinal mobility
• Straight leg raising test:
limited to 40° (left side) & 90°(Right side)

16. Systemic examinations
Other systemic examination was normal

17. A 66 years old diabetic gentleman got admitted with
the complaints of progressive difficulty in walking
with dull aching, mild low back pain radiating to left
leg, associated with retention of urine. He had
anaemia, restricated spinal mobility & tenderness on
lower spine. on examination of lower limbs, he had
wasting, hypotonia, diminished muscle power,
areflexia, absent plantar & antalgic gait. All
modalities of sensation was diminished at L4/L5/S1
dermatomal distribution on left side along with
saddle anaestheisa . SLR was restricted on left side.
Other systemic examination was normal.
Salient feature

18. Provisional diagnosis
• Diabetes Mellitus Type 2
• Cauda equina syndrome due to discitis
or metastasis?

19. Differential diagnosis
• Conus medullaris syndrome
• Traumatic peripheral nerve lesions
• Acute inflammatory demyelinating
polyradiculoneuropathy

20. Investigations
CBC:
Hb % - 8.2
WBC -6800 cu/mm
Neu-65 %
Lymph- 30%
Mono -3 %
Eosino- 1.1%
Platelet- 156000
ESR- 120mm in 1st hour
MCV: 90.3
MCH: 33.2
MCHC:36.9
PBF: Nonspecific morphology

21. S. Electrolytes
Na-137 mmol/l
K-4.5 mmol/l
Cl: 106 mmol/l
HCO3: 26 mmol/l
Ca- 9.3 mmol/l
Mg- 0.9 mmol/l
Phosphate-3.7

22. Lipid profile:
TG: 176 mg/dl
T. Chol : 164 mg/dl
LDL: 95 mg/dl
HDL:36 mg/dl
LFT:
ALT: 34 iu/L
AST: 37 iu/L
S. Total protein: 86.2
S Alb: 26.9
RFT:
S. Creatinine: 0.8mmol/l
S Urea: 29 mmol/l
HbA1c: 7.2%

23. Sugar - Nil
Albumin –Nil
Ketone- Nil
Epi. cell:Afew /HPF
Pus cell: 1-2 /HPF
RBC: Nil
URINE R/M/E

24. • Blood group: AB +ve
• Iron profile:
– S Iron: 7.7
– TIBC: 27.2
– S ferritin: 312
– T sat: 28 %

25. Chest X-Ray
NORMAL

26. ECG
Normal

27. X ray Lumbosacral spine
• Fracture L5
Vertebrae

28. MRI of Lumbosacral spine
• Collapse with altered signal intensity in L5 &
focal altered signal intensity in L3, S1 vertebrae
• Central & paracentral disc bulge causing thecal
sac indentation & bilteral lateral recess
narrowing at L5/S1 level

29. MRI of Lumbosacral spine

30. MRI of Lumbosacral spine

31. MRI of Lumbosacral spine

32. MRI of Lumbosacral spine
• Appearance: clear
• Protein: 66g/L
• Sugar: 4.2mmol/L( Corresponding blood
glucose-6.8 mmol/l)
• Cell count:
• Total WBC : Nil
• Total RBC: Nil
• Bacterial antigen: Negative

33. • USG of whole abdomen: Normal
• S. PSA: 1.13
• S CEA: 2.74
• CA-19.9: 26.4
• Alpha feto protein: Normal

34. • Urine for bence jones protein: Absent

35. X ray Skull lateral view
• Multiple
lytic lesion
is present

36. Serum protein electrophoresis
• Monoclonal band(? M
protein)

37. CT guided FNAC
• Tissue from lumbar
vertebral body L5:
Multiple myeloma

38. Bone marrow examination
• Grossly increased
plasma cells almost
completely replacing
normal haemopoeitic
cells replacing more
than 80% of eisting
marrow cells. The cells
are distributed in sheets
& clusters & include
some immature forms
consistent with multiple
myeloma

39. Bone marrow examination

41. Final diagnosis:
• Diabetes Mellitus Type 2
• Cauda equina syndrome due to multiple myeloma

42. Treatment:
Short acting insulin
Daily physiotherapy
Vitamin B
Calcium
I/V Dexamethasone
Blood Transfusion

43. Hospital course
Patient was immediately transferred to DMCH with prior
consultation to haematologist & neurosurgeon for
radiotherapy, antimyeloma therapy after confirmation of
diagnosis.

44. Follow UP
Patient was advised to follow up in Neurology after 1
month for further clinical evaluation & management.

45. Discussion

46. Case Discussion
• Multiple myeloma is a condition of malignant plasma cell
proliferation derived from a single B-cell lineage
• Making the diagnosis includes demonstrating M-proteins
in either serum or urine, proving the presence of more
than 10% of these malignant plasma cells in the bone
marrow and observing the clinical manifestations of the
disease in our patient
• Up to 30% of patients are diagnosed incidentally while
being evaluated for unrelated problems, while another
third are diagnosed following a fracture .

47. Case Discussion
• The incidence of bone pain from osteolytic lesions
ranges from 58% to 66% of patients with myeloma
• Spinal cord compression following vertebral
compression fractures or vertebral plasmacytomas
comprises 5% of the presentations of multiple
myeloma
• Recent articles revealed few case reports of
plasmacytomas as initial presentations of multiple
myeloma.

48. Cauda Equina Syndrome
Cauda equina syndrome refers to a characteristic
pattern of neuromuscular and urogenital symptoms
resulting from the simultaneous compression of
multiple lumbosacral nerve roots below the level of
the conus medullaris. These symptoms include low
back pain, sciatica, saddle sensory disturbances,
bladder and bowel dysfunction, and variable lower
extremity motor and sensory loss.

49. Cauda Equina and Conus Medullaris
Syndromes

50. Etiology
• Spinal trauma including fractures
• Neoplasm, including metastases
• Spinal infection/abscess
• Idiopathic
• Spinal hemorrhage
• Multiple sclerosis
• Spinal arteriovenous malformations
• Late-stage ankylosing spondylitis
• Neurosarcoidosis

51. History
Patients can present with symptoms of isolated
cauda equina syndrome, isolated conus medullaris
syndrome, or a combination. The symptoms and
signs of cauda equina syndrome tend to be mostly
lower motor neuron (LMN) in nature, while those of
conus medullaris syndrome are a combination of
LMN and upper motor neuron (UMN) effects

52. History
• Low back pain
• Unilateral or bilateral sciatica
• Saddle and perineal hypoesthesia or anesthesia
• Bowel and bladder disturbances
• Lower extremity motor weakness and sensory
deficits
• Retention, Difficulty initiating micturition, Decreased
urethral sensation. urinary manifestations begin with
urinary retention and are later followed by an
overflow urinary incontinence.

53. Physical examination
• Muscle strength in the lower extremities is diminished.
• Sensation is decreased to pinprick and light touch in a
dermatomal pattern corresponding to the affected nerve
roots.
• Vibration sense may also be affected.
• Muscle stretch reflexes may be absent or diminished in
the corresponding nerve roots.
• Babinski reflex is diminished or absent.
• Anal sphincter tone is patulous
• Muscle tone in the lower extremities is decreased, which
is consistent with an LMN lesion.

55. Physical Examination

56. Diagnostic Considerations
• AIDP
• Amyotrophic lateral sclerosis
• Diabetic Neuropathy
• Guillain-Barré Syndrome
• Multiple sclerosis
• Neoplasms of Spinal Cord
• Neurosarcoidosis
• Spinal Cord Infections
• Traumatic

57. Complications
• Neurogenic bladder/bowel
• Erectile dysfunction
• Pressure ulcers
• Osteoporosis
• Chronic neuropathic pain
• Spasticity/contractures
• Recurrent urinary tract infections
• Urethral stricture
• Bladder calculi
• Depression

58. • Corticosteroids
• Skeletal Muscle Relaxants
• AntimyelomaTherapy
• Radiotherapy
• Surgery
• Vertebral Augmentation
• Rehabilitation
• Physical therapy
• Occupational therapy
• Orthotic/assistive devices may be needed

59. Radiotherapy
• External beam radiation therapy represents the treatment
of choice for solitary plasmacytoma of the bone
• In MM, radiation to the spine is usually employed in
patients with uncontrolled pain or in case of vertebral
fracture or spinal cord compression

60. Surgical Decompression
• In acute compression of the conus medullaris or
cauda equina, surgical decompression as soon as
possible becomes mandatory
• In a more chronic presentation, decompression
could be performed when medically feasible and
should be delayed to optimize the patient's medical
condition

61. Morbidity is determined by the underlying etiology.
The prognosis improves if a definitive cause is identified
and appropriate treatment occurs early in the course.