Q for the neurologists

[Jitter Bug]

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Hi there, I am a PM&R doc, and I have a patient I was wondering about your thoughts. Don't worry I have already referred her to a real live neurologist, but that may take a week or two and I'm dying of curiosity.

50-ish British female, referred to my clinic for back pain and leg weakness. Turns out she doesn't really have back pain, but feels her legs get weak and she has fallen at least once. She says her brother told her last week she walks like she is weaving. She goes to Silver sneakers, but never falls because she deliberately puts her foot down firmly on the ground so as not to lose her balance. Says she has had overall poor balance for years.

Gait: She pulls to the left for a few steps, then corrects herself with a quick turn. Pulls to the rigth a few steps, and does the same thing. Subtle, not obvious.

Romberg: positive she sways within 3-4 seconds of closing her eyes.

Cerebellar: only subtle altered left hand rapid tap, fnf fine and heel shin heel fine.

mental status intact.

MSK: normal lumbar ROM, strength, DTR, clonus, babinskis, gross sensation to light touch. She can go from sit to stand without assist, and she can squat and rise without assist.

If you had to put a dollar on her diagnosis, what would you guess?

 

[AlternateSome1]

With a weakly positive Romberg and her feeling the need to deliberately place the feet, I would initially think of a peripheral neuropathy. You mention under "MSK" that she has "clonus, babinskis". You seem to lump those in with normal findings, so I assume you mean they are not present. If they were, then the presentation would be more suggestive of an upper motor neuron process. With that combination and fairly preserved strength, then I would consider the possibility of a subacute combined degeneration from B12, or another spinal process. However, you can't make much out of this case without a better sensory examination.

 

[danielmd06]

50-ish British female, referred to my clinic for back pain and leg weakness. Turns out she doesn't really have back pain, but feels her legs get weak and she has fallen at least once. She says her brother told her last week she walks like she is weaving. She goes to Silver sneakers, but never falls because she deliberately puts her foot down firmly on the ground so as not to lose her balance. Says she has had overall poor balance for years.

Gait: She pulls to the left for a few steps, then corrects herself with a quick turn. Pulls to the rigth a few steps, and does the same thing. Subtle, not obvious.

Romberg: positive she sways within 3-4 seconds of closing her eyes.

Cerebellar: only subtle altered left hand rapid tap, fnf fine and heel shin heel fine.

mental status intact.

MSK: normal lumbar ROM, strength, DTR, clonus, babinskis, gross sensation to light touch. She can go from sit to stand without assist, and she can squat and rise without assist.

If you had to put a dollar on her diagnosis, what would you guess?

I typed a very laborious answer to you yesterday but wound up deleting it. Basically, it dovetails with what AlternateSome1 posted. You leave us with confusing references to clonus and "babinskis" and an overall decided paucity of data, sir. Very incomplete history, absence of medications/vitamins, and very incomplete physical exam. To quote Sherlock Holmes: "I cannot make bricks without clay!"

With what you've typed, the story sounds like an ataxic gait suggestive of dorsal column dysfunction. I would consider vitamin B12 deficiency, B6 toxicity, copper deficiency, and neurosyphilis.

 

[neglect]

With what you've typed, the story sounds like an ataxic gait suggestive of dorsal column dysfunction. I would consider vitamin B12 deficiency, B6 toxicity, copper deficiency, and neurosyphilis.

Things are so vague that I don't think it localizes to the spine. Instead, if this is neurologic, would think a mild peripheral neuropathy. Many times there are no neurologic problems and the gait problem is instead referable to obesity, deconditioning, arthritis, and medical issues.

This case highlights some interesting issues though. One, that we'll never be out of a job. For another, that neurologic training is generally bad and in specific cases might be terrible, but neurologic conditions and mimics are very common. And what does this say about PM&R?

 

[danielmd06]

Things are so vague...QUOTE]

Yes. Hence, my qualifying comments.

 

[Mattchiavelli]

I think even doing a functional type exam one big thing for me is lacking- tho she stands with no assist can she do it without using her arms? Is there more info on the muscular exam of the hip girdles?

and yes I agree med list is important along with med history... doing consults this month I've come to diagnoses multiple times just asking about medications and their actual use vs how they are written. Example- if you're 80 and have been taken up to 10mg valium QID PRN "nerves" and are also on anticholinergic muscle relaxants you might not be walking very well...not exactly the oldschool twilight sleep of an opiate and an anticholinergic but close