Foot-Drop Case Presentation
Foot-Drop Case Presentation in simple text form:- Slide 2: The Case of Mr. A. 40 year old man Self-employed systems administrator Divorced Lives with girlfriend R handed Presented with a 2 week history of back pain and difficulty walking AskTheNeurologist.Com Slide 3: HPC 2 weeks prior to admission Lower back pain ( more on R) Started tripping and falling ( no injury) Urinary incontinence dripping Presented to ER , on examination weakness of R ankle dorsiflexion found CT: mild discopathy L3 - S1 without suspicion of root compression Discharged with recommendation to continue investigation as out-patient AskTheNeurologist.Com Slide 4: HPC II Following discharge Continued to fall ( x4) with no injury Urinary problems resolved spontaneously 10 days later Loss of anal sphincter control Unaware of passing stool except for smell No change in state of leg Presented to ER 3 days later with no change AskTheNeurologist.Com Slide 5: HPCIII Patient denies Urinary problems Erectile dysfunction Sensory disturbances Arm or left leg weakness Definable psychological trauma in previous year AskTheNeurologist.Com Slide 6: PMH I Age 9 Hospitalised for 1 year According to patient unable to move legs with total anaesthesia below waist Possibly associated with sphincter disturbance no diagnosis found Spontaneously recovered under interesting circumstances ! AskTheNeurologist.Com Slide 7: PMH II Similar episodes recurred at least 3 times: Aged 11 years Aged 14 years Aged 17 years Each episode would last a few hours and was usually hospitalised and discharged without a diagnosis AskTheNeurologist.Com Slide 8: PMH III Aged 32 Following mothers death had episode of feeling legs frozen below knees Resolved spontaneously after arriving in ER AskTheNeurologist.Com Slide 9: PMH IV Aged 35 Hospitalised with DVT + SVT left leg Treated with heparin and then warfarin Borderline homocysteine ( according to pt) 14 nmol / ml ( 0-15) AskTheNeurologist.Com Slide 10: PMH IV 4 months prior to admission Admitted to Neurology ward Left leg superficial thrombophlebitis Global weakness right arm ( 4/5) Distal > Proximal weakness Left leg Reflexes ++ symmetrical No pyramidal sings Sensory loss stocking on left NCV + LP normal Weakness improved spontaneously AskTheNeurologist.Com Slide 11: Social History Smokes 1 pack / day Divorced 2 years ago following marriage of 8 months ( infidelity of partner) Currently lives with girlfriend of 3 months No children Self- employed, business going well AskTheNeurologist.Com Slide 12: Examination in ER CNs intact Tone intact Power Preserved in arms and L Leg Weakness R leg DF INV EV PF preserved ? Decreased right achilles reflex No pyramidal signs AskTheNeurologist.Com Slide 13: Examination in ER II Sensory examination Inconsistent sensory level T8 Decreased vibration sense R leg only No cerebellar signs Gait Antalgic / paretic ( R Leg) Anal sphincter tone intact with normal perianal sensation AskTheNeurologist.Com Slide 14: During hospitalisation No nursing observations regarding sphincter disturbances One episode of fever > 38.0 Request to receive heparin injections for a DVT he suspects he has developed Episodes of sudden loss of power in both legs associated with knees giving way Inconsistencies between examiners No real change in right leg function AskTheNeurologist.Com Slide 15: Examination follow-up CNs intact Tone intact Power Preserved in arms and L Leg Weakness R leg TA, EHL, EDB Proximal strength preserved including Glutei Hamstrings INV, EV, PF preserved Reflexes symmetrical No pyramidal signs AskTheNeurologist.Com Slide 16: Examination follow-up II Sensory examination normal No cerebellar signs Gait variable foot drop on R Preserved perianal sensation and anal reflexes AskTheNeurologist.Com Slide 17: Investigations 1 } CBC ESR All normal Biochemistry LP Pressure 8 TP 192 mg / l Glu 3.5 2 lymphocytes AskTheNeurologist.Com Slide 18: Investigations 2 Electrophysiology 3 weeks following onset Normal peroneal CV ( 56 m/s) Normal EDB and TA CMAPs below and above fibular head ( EDB CMAP = 9.0 mv) No spontaneous activity Normal units Little / no voluntary recruitment AskTheNeurologist.Com Slide 19: Electrophysiology timescales Conduction block Occurs within days Demyelinative / early axonal lesion CMAPs Should decrease by 1 week in axonal lesions ( Wallerian degeneration) Fibrillations / PSWs Occur at 7 21 days ( active denervation) Large polyphasic MUPs Occurs after 2-3 months ( chronic denervation) AskTheNeurologist.Com Slide 20: Investigations 3 Brain CT : normal ( 2 ½ weeks following onset) MRI lumbosacral region AskTheNeurologist.Com Slide 21: DD of Foot-drop Muscle NMJ Nerve Deep peroneal Common peroneal Sciatic Lumbosacral plexus L5 radicualopathy ( rarely L4) Motor neuron Cerebral lesion ( cortical / subcortical) Non-organic AskTheNeurologist.Com Slide 22: AskTheNeurologist.Com Slide 23: AskTheNeurologist.Com Slide 24: Two types of disc herniation. Dorsolateral a, lateral -b AskTheNeurologist.Com Slide 25: Dorsal view of the lumbar spine and sacrum showing different types of disc herniation AskTheNeurologist.Com Slide 26: AskTheNeurologist.Com Slide 27: AskTheNeurologist.Com Slide 28: AskTheNeurologist.Com Slide 29: AskTheNeurologist.Com Slide 30: LUMBOSACRAL PLEXUS AskTheNeurologist.Com Slide 31: AskTheNeurologist.Com Slide 32: AskTheNeurologist.Com Slide 33: COMMON PERONEAL NERVE AskTheNeurologist.Com Slide 34: Sural nerve AskTheNeurologist.Com Slide 35: Sensory loss in common peroneal nerve lesions AskTheNeurologist.Com Slide 36: Sensory loss in deep peroneal nerve lesions AskTheNeurologist.Com Slide 37: } Weight loss predisposes AskTheNeurologist.Com Slide 38: AskTheNeurologist.Com Slide 39: AskTheNeurologist.Com Slide 40: DD of Foot-drop Muscle NMJ Nerve Deep peroneal Common peroneal Sciatic Lumbosacral plexus L5 radicualopathy ( rarely L4) Motor neuron Cerebral lesion ( cortical / subcortical) Non-organic AskTheNeurologist.Com Slide 41: DD of Foot-drop Muscle Sudden onset, unilateral, restricted, rarely causes foot-drop as major feature NMJ Focal, no fluctuations, rarely causes foot-drop as major feature Nerve Deep peroneal Absence of motor and sensory Common peroneal involvement expected to be associated with various syndromes Sciatic Lumbosacral plexus Normal NCV / EMG with L5 radiculopathy ( rarely L4) profound weakness ( at 3 weeks) Motor neuron normal EMG Cerebral lesion Rare cause of foot-drop, no other UMN signs, normal Head CT Non-organic Explanation of documented DVT? AskTheNeurologist.Com Slide 42: Deep Venous Thrombosis: Risk Factor Assessment and Diagnosis Emergency Medicine Review 1996 Be alert for psychiatric patients or prisoners who may tie a tourniquet around their thigh to produce factitious DVT. AskTheNeurologist.Com Slide 43: Non-Organic disorders Somatoform disorders Patient believes they have a real disorder Somatisation disorder ( IBS, palpitations etc) Over-interpretation of real physiological phenomena Often reflect an affective disorder Conversion disorder ( hysterical blindness etc) Loss of physical functioning Usually follows acute stress Hypochondriasis More disease-centered than somatisation disorder Factitious disorder ( Munchausen) Intentional production / reporting of clinical features in order to enter sick-role Motives unknown to patient Malingering Intentional production / reporting of clinical features for a conscious concrete gain AskTheNeurologist.Com Slide 44: Munchausen Syndrome Baron Munchausen Served in German Army against Turkey (1700s) Told wild and wonderful stories of life as an adventurer and soldier Most stories untrue Stories were not medically directed AskTheNeurologist.Com Slide 45: Munchausen syndrome II 3 Major presentations Haemorrhagic Abdominal Neurological Triad Dramatic presentation Falsely elaborating symptoms Travel to a number of medical institutions AskTheNeurologist.Com Slide 46: Munchausen Syndrome III Often acquire medical knowledge Health care professionals Independent research Previous hospitalisations Usually like to remain on familiar medical ground Explanation of clinical pattern? AskTheNeurologist.Com Slide 47: Possible evolution Initial 1 year hospitalisation as a child with paraplegia with subsequent frequent relapses Became aware of concept of stasis as a cause for DVT Factitious DVT Attempt to reproduce factitious DVT results in SVT only patient exaggerates weakness in region of painful area .sent to neurologist Hospitalisation in neurology dept, becomes aware of concept of foot-drop ? asked about back-pain, sphincter disturbances May have gained knowledge from earlier hospitalisations Presents with a triad of foot-drop, back pain, sphincter disturbances AskTheNeurologist.Com Slide 48: end of foot-drop presentation Thank you! AskTheNeurologist.Com Author Anon AskTheNeurologist.Com
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