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A 30 year old white man presented to his local hospital with a four day history of lower back pain and leg weakness after a minor fall. His past medical history included a lumbar microdiscectomy eight years before. He was not diabetic and there were no risk factors for immunosuppression. Initial examination showed normal power and reflexes in both legs but there was decreased sensation on the inner aspect of the left calf, scrotum, and perianal area with normal continence. While awaiting investigation he developed an absent left ankle reflex. Magnetic resonance imaging (MRI) of the lumbar spine was then performed (see fig 1), on the basis of which he was referred to the regional neurosurgical unit.
On arrival, the patient was unwell, markedly tachycardic at rest, and dehydrated with severe tenderness in the lumbar spine. Neurological examination demonstrated severe weakness in both lower limbs, predominantly on the right. Plantars were equivocal and reflexes were absent throughout. Patchy sensory loss in both legs was noted which extended up to the inguinal regions, as well as saddle and perianal anaesthesia. He also had reduced anal tone, was in acute urinary retention, and required catheterisation.
What is the most likely clinical diagnosis?
What does the MRI scan show?
Discuss the management of this condition.
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