CAUDA-EQUINA SYNDROME WITH PAGETIC VERTEBRAL FUSION - CLINICAL RECOVERY UNDER CALCIUM VITAMIN-D SUPPLEMENTATION PLUS CLODRONATE AFTER APPARENT FAILURE OF PAMIDRONATE AND ACQUIRED-RESISTANCE TO ETIDRONATE

A patient with an osteolytic L2-L3 pagetic block and pagetic lesions o f L1 and the sacrum seen only as increased radionuclide activity becam e resistant to etidronate after the fifth course (5 mg/kg/d six months per year) and developed severe cauda equina syndrome (reduction in wa lking distance to 30 m and sphincter dysfunction) due primarily to ver tebral hypertrophy, Five months after a ten-day course of intravenous pamidronate (22.5 mg/d), the clinical symptoms were unchanged, althoug h the alkaline phosphatase level was down 50%, Oral clodronate (1600 m g/day for six months per year) in combination with calcium and vitamin D supplementation dramatically improved the walking distance and sphi ncter disorders, Resolution of the neurological manifestations was com plete after the second clodronate course, At last follow-up nine month s after the fourth clodronate course, there was no evidence of a relap se and the alkaline phosphatase level was normal, The time course of e vents in this patient does not allow to affirm that pamidronate was in effective and suggests that calcium and vitamin D supplementation impr oved mineralization of the pagetic block and enhanced the effect of bi sphosphonate therapy.