Foot Drop

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Neurology Case Presentation regarding an unusual case of foot-drop

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Foot Drop

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

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