Clinical reasoning: a case of treatable spastic paraparesis.

Jonathan H. McKinnon, MD E. Peter Bosch, MD, FAAN SECTION 1 A 36-year-old man was referred for progressive lower extremity spasticity. He had a 4-year history of gradually progressive leg stiffness and ankle clonus and a 1-year history of gait disturbance and urinary urgency. There was no history of optic neuritis, diplopia, Lhermitte phenomenon, seizure, cognitive disturbance, paresthesias, or diarrhea. Family history showed no evidence of neurologic disorders in his parents, 4 siblings, and 3 children. Neurologic examination revealed normal mental status and cranial nerves. Cataracts were not seen by slit-lamp examination. There was lower extremity spasticity with sustained ankle clonus, diffuse hyperreflexia, bilateral Babinski and Hoffman signs, and a spastic gait (25foot timed walking: 10 seconds). Vibratory sensation was impaired in the toes bilaterally. Cerebellar signs were not present. The Achilles tendons were enlarged (figure 1). The clinical history and neurologic examination suggest upper motor neuron signs and involvement of large fiber sensory pathways, the combination of which suggests myelopathy or myeloneuropathy. Questions for consideration: 1. What is the differential diagnosis of chronic progressive myelopathy? 2. What diagnostic tests would you order?