Disclosures: Jason L. Kessler, MD: No financial relationships or conflicts of interest

Case Diagnosis: Severe degenerative lumbar spinal canal stenosis with cauda equina nerve root compression

Case Description or Program Description: 82-year-old man with history of degenerative LSS with chronic intermittent radicular symptoms of pain and numbness in right leg, referred for walker for ambulatory dysfunction. Five days prior, the patient reported he fell due to bilateral knee buckling and he reported progressively worsening gait dysfunction until presentation. Previously, the patient ambulated independently with a cane. The patient denied saddle anesthesia, bladder or bowel incontinence, or pain. Physical exam revealed 5/5 lower extremity strength with the exception of 2/5 bilateral knee extension and 4/5 bilateral hip flexion. Sensation was diminished to light touch at right lateral leg. Achilles and patellar reflexes were absent bilaterally, perianal sensation and rectal tone intact. Knees buckled after short distance ambulation with walker requiring maximal assist to recover.

Setting: Outpatient Clinic

Assessment/Results: MRI revealed severe degenerative lumbar spinal canal stenosis L2-L5 with compression of the cauda equina, no herniated disk was identified. After neurosurgery consultation, patient underwent surgical decompression without complication.

Discussion (relevance): The clinical hallmark of degenerative LSS is neurogenic claudication. Patients may also have radiculopathy with focal weakness or sensory loss. If weakness is present, it is usually mild. Course is usually benign, symptoms are mostly stable and treated conservatively. Rapid deterioration with severe bilateral weakness is rare and if present, surgery may be indicated. Literature review reveals rare cases of isolated severe bilateral dorsiflexion weakness with LSS. To our knowledge, bilateral severe quadriceps weakness has not been previously reported.

Conclusions: We present a case of degenerative LSS who developed severe bilateral quadriceps weakness with MRI evidence of compression of the cauda equina. Although the clinical course of degenerative LSS is usually benign, this case highlights the uncommon possibility of progression to severe neurologic disability and underscores the importance of monitoring for clinical progression in this population.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/acute-painless-bilateral-quadriceps-weakness-in-a-patient-with-severe-degenerative-lumbar-spinal-stenosis-lss-a-case-report/