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A Sample Case: A 25 yr old man was playing basketball in a local league when he noticed that his legs were becoming uncharacteristically tired and stiff feeling. At other activities he was less noticeably affected but over a period of weeks the weakness increased even with less strenuous tasks. Except for headaches, which awakened him from sleep, he had no other complaints.

His general physical condition was very good and he had no significant family history or past medical conditions of note. He was alert and well oriented with respect to time and place. He comprehended and spoke well. The cranial nerve exam was normal except for papilledema. His sensory exam was normal for pain, temperature, touch, proprioception, and vibration. His motor exam showed normal strength, tone, reflexes, etc. for both upper extremities but both lower extremities were weak, showed spasticity, and there were bilateral Babinski signs.

Explanation -

Weakness and spasticity of both lower extremities without involvement of the upper limbs indicate an upper motor neuron syndrome of the lower limbs suggesting a lesion in a location where the representation of both legs are close together but separated from the arms. Such locations would be the lateral funiculus of the spinal cord below T1 or the midline of the hemispheres. The spinal cord lesion would likely include the posterior white columns producing loss of conscious proprioception, which in this case was unaffected. The hemispheres are a more likely site since the leg area is far from the arm and motor and sensory functions are separated by the central sulcus.

Papilledema and headache suggested increased intracranial pressure. The gradual onset of symptoms plus radiographic evidence ruled out aneurysms, infarction, and hemorrhage but a midline mass growing on the falx cerebri was detected. A meningioma was diagnosed and removed.