Case 22 A builder tripping over his feet
Tom was a 58-year-old man who ran his own business as a builder. He visited Dr Tugwell complaining that his legs felt heavy. There was no pain. He had previously had osteoarthrosis symptoms in the knees and left hip, and occasionally had low back pain. He had had mild left-sided hand symptoms on and off, suggestive of carpal tunnel syndrome. Dr Tugwell recorded that foot pulses were normal and the legs were ‘neuro nad’. No specific diagnosis was made.
Three months later Tom came back and said that his legs still felt heavy and that it was beginning to trouble him at work. He seemed to trip a lot and was finding ladders difficult. Dr Tugwell examined his knees and hip joints and thought the symptoms were probably a manifestation of arthritis. Naproxen was prescribed.
What would be your differential diagnosis and how would you discriminate between them?
Tom attended A&E a few weeks later. He had accidentally lost his grip on a heavy bucket of cement and dropped it on his foot. When seeing Dr Tugwell for a medical certificate a week later, he commented that he must be getting old because he had never had an accident of the sort before. He commented on his difficulty in walking and Dr Tugwell agreed that this was probably due to the injury to his foot.
Two weeks later Tom consulted the practice registrar, Dr Phillips. He reported increased difficulty passing urine over some months, but a particular difficulty in the last week or so. Dr Phillips did a digital rectal examination and diagnosed benign prostatic hypertrophy. He arranged for a deferred PSA and started him on an alpha blocker.
Tom next consulted Dr Atwell two months later. He was noticing a continuing tendency to drop things. He felt his grip was weak. Dr Atwell examined his hands and could find no specific abnormality but agreed to make a referral for nerve conduction studies. Dr Atwell noticed the Tom’s gait appeared awkward but did not examine him since Tom thought it was due to his foot injury. He requested another X-ray of the foot to exclude a fracture. This was normal.
When Tom attended several weeks later for the nerve conduction studies, the neurophysiologist was so concerned by the patient’s gait that he asked a neurology registrar to see the patient. The registrar noted that Tom had urinary symptoms and that for some months he had had electric shock symptoms in his legs if he bent his neck. He found that power was largely normal but there was symmetrically increased tone in the legs with very brisk knee and ankle reflexes, sustained bilateral ankle and knee clonus and upgoing plantar reflexes. There were no objective sensory signs.
An urgent MRI scan revealed a compressive myelopathy in the cervical spine secondary to a spondyltic bar at the C4/5 level. Decompression surgery was carried out soon after but Tom made only marginal improvement and he had to give up his business.
Tom instructed solicitors who were critical of the failure to record a neurological examination of the legs over a period of some 8 months between the first consultation and the eventual diagnosis.
Do you think his claim will succeed?
Expert comment
Cervical spondylosis is very common in the older population and can present in one of three ways:
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