Case 2: Back Pain and Difficulty Ambulating in a 4-year-old Girl

Case Presentation

A 4-year-old girl presents to the emergency department with a 2-week history of worsening back pain focused around a dimple located in the middle of her back. She has experienced progressive difficulty in ambulating over the same time period, and today she cannot stand or walk without assistance. There is no history of trauma, loss of bowel or bladder control, or urinary retention, but she does have a history of chronic constipation.

On physical examination, her temperature is 37.1°C (98.8°F), blood pressure is 120/72 mm Hg, heart rate is 113 beats/min, and respiratory rate is 22 breaths/min. She has a dimple over the T9 spinous process surrounded by mild erythema. She has exacerbated (4+) patellar and Achilles reflexes. The upper extremity reflexes are 2+ bilaterally. Babinski sign is demonstrated bilaterally. Muscle strength is 3/5 in her lower extremities and 5/5 in her upper extremities. She cannot stand without support and can only take two steps before stating that her legs are tired. Sensations to touch and pain are intact throughout the lower and upper extremities. The rest of the physical examination findings are normal.

Laboratory evaluation shows normal complete metabolic panel and complete blood cell count. Erythrocyte sedimentation rate is 9 mm/hr and C-reactive protein measures less than 2.9 mg/L (27.62 nmol/L).

Magnetic resonance imaging (MRI) of the thoracic spine …