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A 63-year-old right handed man presented with  a 3 day history of severe progressive back pain with lower extremity weakness, numbness and unsteady gait.  There was no history of recent injuries or any other precipitating events. He denied any symptoms in the upper extremities, headache, fever, chills, nausea, vomiting, shortness of breath, chest pain or difficulty  with bowel or bladder function, but complained of decreased appetite. Two years prior to this evaluation, he underwent bilateral orchiectomy for treatment of adenocarcinoma, of the prostate, with pelvic lymph node metastases, followed by antiandrogenic treatment with flutamide. He had no prior history of significant back pain or any neurologic symptoms and his medical history was otherwise unremarkable.

On examination, his vital sign were normal. He had tenderness over T7 and T8 spinal processes. Mental status and cranial nerves were normal. Motor exam showed normal bulk and tone, and bilateral grade 4/5 lower extremity weakness. Sensory examination showed diminished sensation to pain and light touch below the level of the T8 dermatome, and marked loss of vibratory sensation and proprioception of both legs. Deep tendon reflexes were normal in the upper extremities, and grade 3 in the lower extremities. Cremasteric reflex was normal. Anal sphincter tone was mildly decreased. He had bilateral Babinski signs. Coordination was normal in the upper extremities, and he had mild difficulty with heel-to-shin testing bilaterally. His gait was unsteady and he had marked difficulty with tandem gait testing. 

QUESTIONS:  CASE SUMMARY 11

1)     What is the localization – most likely anatomic structures?  

2)     What is the most likely cause?

3)  What urgent evaluation in needed?

4)     What emergent therapy is required?