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Post lumbar puncture leg weakness mimicking cauda equina syndrome.

Case report A 60-year-old man was scheduled for his third cycle of intrathecal Methotrexate as prophylaxis central nervous system treatment for Stage 1Ae diffuse large B cell lymphoma of the left nasal cavity. His previous lumbar puncture (LP)s were technically difficult. Due to his prior traumatic experience, it was decided that more analgesia be administered locally to alleviate his pain and anxiety. The patient was well built and slim, mobilised independently prior to LP. He had neither medical problems nor medications prior to his diagnosis and had no allergies. He had normal platelet count and coagulation screen. Under aseptic technique, standard landmarks were identified. The patient was positioned in the left lateral position. L3 and L4 disc space interfaces were identified. Skin and subcutaneous tissue was infiltrated with eight millilitre (ml) of one percent Lignocaine using a 21 gauge needle. Routine aspiration was performed during administration of local anaesthetic with no venous flashback. LP was performed using a 22 gauge tuhoy needle with a single pass using the same tract. The patient tolerated the procedure well. Five ml of initial bloody cerebrospinal (CSF) fluid eventually became colourless. CSF fluid was sent for analysis (Table 1) after which 12.5mg in 5ml of intrathecal Methotrexate was administered by a certified doctor as per protocol. There was no resistance on intrathecal chemotherapy administration. The patient described sensation of gradual onset paraesthesia followed by bilateral persistent leg weakness upon removal of the LP needle. He denied any back pain, nausea, or headache. His vital signs were stable. Lower limb neurology showed reduced tone bilaterally & absent reflexes. Babinski reflex was down going. Power on hip flexion, & knee extension was 4-/5. Power on foot dorsiflexion, plantar flexion & knee flexion was 3/5.