LESIONS

A Guide to Localisation in Neurology

Case 4. Progressive lower limb numbness

Case

A 60 year old woman presented with several months of progressive sensory disturbance in the lower limbs.

This began in the soles of the feet, and she felt as if her socks were 'wrinkled'. It progressed over weeks to affect the dorsal feet, then the lower aspects of the legs, and gradually ascended in the next few months to the shins, then progressive above the knees and eventually reaching to the groin and perineal areas, and subsequently the umbilical area - in a circumferential distribution around to the back, at the same level, as if she had been dipped in water up to the umbilicus. Everything above this felt normal. While she still had feeling in the affected area if she touched herself, it felt altered. She also felt some hypersensitivity to touch in the affected regions at times.

In addition to this she noted a sense of urinary urge, though was still able to void on command, and had not had any incontinence of urine. When she defecated she had intact continence but the action felt altered, and she had altered sensation on wiping.

There were no motor features and nothing abnormal in the upper limbs or cranial segment.

She had a past history of breast cancer 15 years prior, treated with surgical resection, with no evidence of recurrence over several years of follow-up, and had been given the 'all-clear' and discharged.

On examination:

• Sensation to touch and vibration were altered to the level of the umbilicus (including around the lower back at the same level), but normal above this
• Proprioception was altered bilaterally - she could correctly identify the toe position, but it felt strange, and took longer than it normally would
• Pinprick sensation was intact
• Lower limb motor function was normal, including reflexes

Upper limb and cranial nerve examination was normal, lotor and gait examination (including reflexes) were normal