The Losses in Lulu's Legs

Lulu is a previously well, 39-year-old woman, who has noted increasing weakness in her legs over the past month. She is now unable to walk without assistance. One year ago, she noted paresthesias in her feet which have gradually worsened. More recently, she has had tingling in her hands. She has had no back or neck pain. However, she has noted increasing urinary urgency, and had been incontinent on 2 occasions.

Examination reveals a normal mental status and cranial nerves. Arm strength is normal. The legs are stiff and moderately to severely weak: she is able to stand from a sitting position only with assistance. Her gait is also stiff, narrow-based, and unsteady, and she tends to circumduct her legs. When she closes her eyes, she topples forward. Light touch and pain perception are normal, but both joint position sense and vibratory sensation are diminished in the arms and legs. Deep tendon reflexes are increased in the arms and at the knees, but are absent at the ankles. Plantar responses are extensor bilaterally.

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