Case presentation

[lobelsteve]

50 y/o WM with no sig PMH. Seen in consult 5 months after sudden onset of right foot drop. No surgery, no trauma, only leg crosssing behaviors present. He awoke with strange sensation in his whole right leg and within a few hours had weakness in his ankle, but not in the hip or knee flex/ext.

He has inversion as well as eversion weakness tested in dorsiflexion.
3/5 EHL 3/5 DF 3/5 inverters 3+/5 everters

Studies: MRI knee, pelvis, brain (all normal-but all had a reason to order based on addition clinical history and exam)

EMG x2- waveforms not available, Abnormal activity in b/l paraspinals, right gluteus medius, right edb, right ta, normal: left edb, left ta, b/l med and lat gastroc, vastus med, vastus lat, tfl, bflh, bfsh.

Sural left 1.5 / 7.8 right 4.25 / 19
Sup Per left 1.75 / 6.2 right 1.8 / 7.6

F's and H's normal

Motor:

Right EDB ankle 4.4 / 2.5 knee amp 2.7 vel 42.1
Left EDB ankle 2.15 / 8.2 knee 3.5 40.2

Right AH 3.0 10.1
Left AH 4.25 0.6


Has been doing home exercise program and is now 4/5 strength. Still unable to play golf or jog, but otherwise does not effect him much.

Idiopathic, compressive neuropraxic, ALS, MS, ???

From top to bottom, no clear answer in the imaging. EMG maybe misleading, I did not do it and do not have waveforms to look at, and I trust the Neurologist who performed them.

Thoughts?

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[caedmon]

Could the paraspinal changes be a red herring?

Seems to localize proximally, possibly a radiculoplexus neuropathy. would consider this with sensory and motor changes, and may be isolated to one root level. More common in diabetics but can also be seen in those with glucose intolerance. Does the patient have risk factors for metabolic syndrome? i.e. big person?

I guess HNPP would be a consideration, however, this again seems a little to proximal.

If the patient has significant facet degnerative changes the paraspinals could be from affects on the dorsal rami and somewhat midleading.

 

[lobelsteve]

No DM. No PMH. Had borderline HTN and increased cholesterol at the time the foot drop occurred. BP improved on its own, chol lowered on meds. No CVA, not a large man, athletic build, used to jog daily. MRI L-spine with no root impingement- Neurologist sent him to me to work this up further, but as he has no pain, I just asked what he wanted me to do. We got a myelogram to further assess (normal) and I got to give him a blood patch for the PDPH.

 

[Myofascist]

This could be a zebra but cant certain tumors affect the lumbosacral plexus w/o showing up on MRI. These abnormalities seem very spotty, possibly fascicular sparing. Even fascicular sparing cant explain abn glut med w/ normal tfl though. Tough to put the pt through another test but...

 

[PMR 4 MSK]

Peroneals should have been tested across the knee - most common site of peroneal entrapment is at or above fibular head, kinda like a cubital tunnel syndrome. There may some conduction block there based on the amplitude drop of the peroneal at the knee. Abnormal activity in the right EDB and TA also point to this. When bilateral paraspinals show Fibs and PSWs with a normal MRI of the L-SPine, I ignore them - 5-10 % normals may have these

I've MRI'd a number of these knees and they're usually normal. There's an ortho in Madison who'll do releases of the peroneal at the knee. Don't know of any outcome data.

 

[spondy14]

50 y/o WM with no sig PMH. Seen in consult 5 months after sudden onset of right foot drop. No surgery, no trauma, only leg crosssing behaviors present. He awoke with strange sensation in his whole right leg and within a few hours had weakness in his ankle, but not in the hip or knee flex/ext.

He has inversion as well as eversion weakness tested in dorsiflexion.
3/5 EHL 3/5 DF 3/5 inverters 3+/5 everters

Studies: MRI knee, pelvis, brain (all normal-but all had a reason to order based on addition clinical history and exam)

EMG x2- waveforms not available, Abnormal activity in b/l paraspinals, right gluteus medius, right edb, right ta, normal: left edb, left ta, b/l med and lat gastroc, vastus med, vastus lat, tfl, bflh, bfsh.

Sural left 1.5 / 7.8 right 4.25 / 19
Sup Per left 1.75 / 6.2 right 1.8 / 7.6

F's and H's normal

Motor:

Right EDB ankle 4.4 / 2.5 knee amp 2.7 vel 42.1
Left EDB ankle 2.15 / 8.2 knee 3.5 40.2

Right AH 3.0 10.1
Left AH 4.25 0.6


Has been doing home exercise program and is now 4/5 strength. Still unable to play golf or jog, but otherwise does not effect him much.

Idiopathic, compressive neuropraxic, ALS, MS, ???

From top to bottom, no clear answer in the imaging. EMG maybe misleading, I did not do it and do not have waveforms to look at, and I trust the Neurologist who performed them.

Thoughts?

If there is one thing that I have realized out in private practice..trust nobody! Even though you trust the neuro..we interpret our EMG's differently, our PE's are mis-interpreted, and the radiology reports MUST be confirmed with your own eyes. So in this case, I would consider repeating a couple pieces of the EMG/NCV, to "follow progression" although his improvement makes it difficult to do much more and you would expect him to continue to improve.

 

[caedmon]

Even if you do peroneals across the knee and find an abnormality I'd try to rule out HNPP before doing a release. There was no trauma, only leg crossing. It may be a compression at the fibular head, but training at a place where you see a lot of zebras, you see lots of nerve releases for uncommon disorders without improvement. I would ask if there's any family history. There are genetic tests available. It would improve clinically like this patient but may be good to know for future reference.

 

[lobelsteve]

Even if you do peroneals across the knee and find an abnormality I'd try to rule out HNPP before doing a release. There was no trauma, only leg crossing. It may be a compression at the fibular head, but training at a place where you see a lot of zebras, you see lots of nerve releases for uncommon disorders without improvement. I would ask if there's any family history. There are genetic tests available. It would improve clinically like this patient but may be good to know for future reference.

OK, OK. I have been holding back on some history. His father has myotonic dystrophy. The patient has some gastroc or soleus atrophy. It is not purely peroneal as the tibial involvement with inverter weakness and gastroc atrophy is present. No clasp knife reflexes, no CRD's or myotonic discharges.

As fas as interpreting the EMG- I work with the Neurologist and would not step on his toes to get a look at the saved study on the machine. THe patient wants to go to another Neurologist for a second opinion (to see the Neurologist who cared for his dad). I'm all for it- after all I'm the pain doc and he doesn't hurt. Got him a PLS orthotic to try when golfing. I'm awaiting blurred vision, weakness somewhere else, or other neurological event to push him into another diagnostic category......