The patient is a 79-year-old male with a past medical history of atrial fibrillation and diabetes mellitus who presented in March 2000 to a Neurologist with a 6-month history of progressive bilateral lower extremity weakness, urinary retention, and constipation with occasional bowel incontinence. He also noted that his symptoms were worse standing or walking and improved with lying down or while using his stationary bicycle. His initial work-up included a radiograph of the lumbar spine that was unremarkable. Thyroid stimulating hormone level, creatinine phosphokinase level, vitamin B12 level, and erythrocyte sedimentary rate were normal. The patient did not pursue further work up including an MRI at that time. He then presented to the Palo Alto Veterans Affairs Hospital on 15 April, 2000 with a complaint of inability to walk or void after a fall while getting out of bed. On examination, the patient's vital signals were: blood pressure, 146/92; pulse, 104; temperature, 36.2°C and finger stick blood sugar, 214 mg/dl. He was alert and cooperative. Speech was fluent and appropriate. Cranial nerves II to XII were intact. Sensory exam revealed pin prick intact up to T6 and impaired below. On motor examination the patient had 4/5 strength in the upper extremities, 2/5 hip flexors and hip extensors and 3/5 knee flexion, knee extension, ankle dorsiflexion and ankle plantar flexion. Reflexes were 3/4 bilaterally in the upper and lower extremities. Rectal tone was slightly decreased. Prostate examination revealed a hypertrophied prostate without palpable nodules. The patient had 1200 cc of urine in his bladder by catheterization. An emergent MRI of the complete spine was done. At that time, there was moderate cervical stenosis seen at C3–4 as well as some evidence of a compression fracture in the thoracic spine.

Due to the complex anatomy and risk, the patient refused intervention other than medical treatment. Therefore no surgical or vascular interventions were offered. The patient underwent a comprehensive rehabilitation program at the spinal cord unit. At discharge the patient was independent in activities of daily living. He was able to ambulate up to 300 feet using a front wheel walker and required a manual wheelchair for community mobility. The patient's bowel program was digital stimulation every other day and his bladder was managed with a Foley catheter.

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