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acute wrist drop

Discussion in 'MSK and EMG Case Discussions' started by PMR 4 MSK, Dec 17, 2008.

  1. PMR 4 MSK

    PMR 4 MSK Large Member
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    47 yo female with bilateral hand numbness. I did EMG 2 weeks ago, had normal NCS of bilateral median and ulnar motor and sensory nerves, including F-waves, needle EMG was normal.

    A few days ago she developed sudden left wrist drop - 2/5 strength of the wrist and finger extensors, normal triceps strength. I got asked to check the radial nerve. I told referring doc it was of limited value this early. NCS completely normal to EIP from forearm, elbow, below and above radial groove, radial sensory normal. Median motor was unchanged, used as a reference. Needle exam showed decreased voluntary motor activity of EDC, ECU, EIP, sort of rapid recruitment, normal MUAP morphology, no spontaneous waves or increased insertional activity.

    Pt also recently had an episode of disorientation, was taken to ER, found on head CT to have non-communicating hydrocephalus. She reports no LOB, but some recent stress incontinence and some emotional lability. Neuro exam except the wrist drop basically normal except positive Hoffman's sign bilaterally but negative Babinski. Reflexes, stregth, sensation and other 3 limb coordination normal. CN exam normal.

    I know that peripheral nerve findings won't normally show up for a few weeks, and CNS does not normally give EMG findings. Would anyone here think that NPH would cause the wrist drop? I've never seen it as a presenting symptom/sign for NPH. She sees a neurosurgeon next week.
     
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  3. olafa

    10+ Year Member

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    Any suspision of lead toxicity, though typically occuring bilateral? Just a thought.

    Alex = australian cattle dog + labrador? Did you do the wisdom panel DNA testing?
     
  4. PMR 4 MSK

    PMR 4 MSK Large Member
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    Didn't think about lead, but should have.

    I didn't know they could do DNA testing - I'll have to ask the vet about that!
     
  5. SSdoc33

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    strange. you have a neuro findings on exam, an abnormal head CT and a "normal" EMG. i say you go where the money is and take a look at her brain. she needs an MRI and sooner rather than later b/c you dont yet have a diagnosis. if there is something reversible, i know id like to catch it early. that said, this is a strange presentation for NPS or a stroke. alsom a c-spine MRI mightbe wise if the brain is negative. let us know how it turns out.
     
  6. Ludicolo

    Ludicolo Fib Hunter
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    Never heard of or seen NPH present like this (bilateral hand numbness and unilateral wrist drop). Lead toxicity is a good idea, but chances are workup will be negative. The "sort of rapid recruitment, decreased voluntary motor unit activity" sounds like poor activation - consistent with a CNS process. Agree with MRI'ing sooner rather than later.

    If she doesn't get better after the surgeon is done with her, repeating the EMG is a reasonable idea. But so far, this sounds central.
     

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