Foot Drop

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Information about Foot Drop

Published on June 6, 2007

Author: NeurologyGuru

Source: slideshare.net

Description

Neurology Case Presentation regarding an unusual case of foot-drop

FOOT DROP AskTheNeurologist.Com Author Anon

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

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

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

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

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

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

HPCIII Patient denies Urinary problems Erectile dysfunction Sensory disturbances Arm or left leg weakness Definable psychological trauma in previous year

Patient denies

Urinary problems

Erectile dysfunction

Sensory disturbances

Arm or left leg weakness

Definable psychological trauma in previous year

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 !

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 !

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

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

PMH III Aged 32 Following mother’s death had episode of feeling legs “ frozen” below knees Resolved spontaneously after arriving in ER

Aged 32

Following mother’s death had episode of feeling legs “ frozen” below knees

Resolved spontaneously after arriving in ER

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)

Aged 35

Hospitalised with DVT + SVT left leg

Treated with heparin and then warfarin

“ Borderline” homocysteine ( according to pt)

14 nmol / ml ( 0-15)

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

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

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

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

Examination in ER CN’s 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

CN’s 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

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

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

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

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

Examination follow-up CN’s 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

CN’s 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

Examination follow-up II Sensory examination normal No cerebellar signs Gait variable “ foot drop” on R Preserved perianal sensation and anal reflexes

Sensory examination normal

No cerebellar signs

Gait variable “ foot drop” on R

Preserved perianal sensation and anal reflexes

Investigations 1 CBC ESR All normal Biochemistry LP Pressure 8 TP 192 mg / l Glu 3.5 2 lymphocytes }

CBC

ESR All normal

Biochemistry

LP

Pressure 8

TP 192 mg / l

Glu 3.5

2 lymphocytes

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

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

Electrophysiology timescales Conduction block Occurs within days Demyelinative / early axonal lesion CMAP’s Should decrease by 1 week in axonal lesions ( Wallerian degeneration) Fibrillations / PSW’s Occur at 7 –21 days ( “ active denervation”) Large polyphasic MUP’s Occurs after 2-3 months ( “ chronic denervation”)

Conduction block

Occurs within days

Demyelinative / early axonal lesion

CMAP’s

Should decrease by 1 week in axonal lesions

( Wallerian degeneration)

Fibrillations / PSW’s

Occur at 7 –21 days ( “ active denervation”)

Large polyphasic MUP’s

Occurs after 2-3 months ( “ chronic denervation”)

Investigations 3 Brain CT : normal ( 2 ½ weeks following onset) MRI lumbosacral region

Brain CT : normal

( 2 ½ weeks following onset)

MRI lumbosacral region

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

Muscle

NMJ

Nerve

Deep peroneal

Common peroneal

Sciatic

Lumbosacral plexus

L5 radicualopathy ( rarely L4)

Motor neuron

Cerebral lesion ( cortical / subcortical)

Non-organic

 

 

Two types of disc herniation. Dorsolateral –a, lateral -b

Dorsal view of the lumbar spine and sacrum showing different types of disc herniation

 

 

 

 

LUMBOSACRAL PLEXUS

 

 

COMMON PERONEAL NERVE

Sural nerve

Sensory loss in common peroneal nerve lesions

Sensory loss in deep peroneal nerve lesions

Weight loss predisposes }

 

 

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

Muscle

NMJ

Nerve

Deep peroneal

Common peroneal

Sciatic

Lumbosacral plexus

L5 radicualopathy ( rarely L4)

Motor neuron

Cerebral lesion ( cortical / subcortical)

Non-organic

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 Common peroneal Sciatic Lumbosacral plexus L5 radiculopathy ( rarely L4) Motor neuron normal EMG Cerebral lesion Rare cause of foot-drop, no other UMN signs, normal Head CT Non-organic Explanation of documented DVT? Absence of motor and sensory involvement expected to be associated with various syndromes Normal NCV / EMG with profound weakness ( at 3 weeks)

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

Common peroneal

Sciatic

Lumbosacral plexus

L5 radiculopathy ( rarely L4)

Motor neuron normal EMG

Cerebral lesion Rare cause of foot-drop, no other UMN signs, normal Head CT

Non-organic Explanation of documented DVT?

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 .”

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

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

Munchausen Syndrome Baron Munchausen Served in German Army against Turkey (1700’s) Told “ wild and wonderful stories” of life as an adventurer and soldier Most stories untrue Stories were not medically directed

Baron Munchausen

Served in German Army against Turkey (1700’s)

Told “ wild and wonderful stories” of life as an adventurer and soldier

Most stories untrue

Stories were not medically directed

Munchausen syndrome II 3 Major presentations Haemorrhagic Abdominal Neurological Triad Dramatic presentation Falsely elaborating symptoms Travel to a number of medical institutions

3 Major presentations

Haemorrhagic

Abdominal

Neurological

Triad

Dramatic presentation

Falsely elaborating symptoms

Travel to a number of medical institutions

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?

Often acquire medical knowledge

Health care professionals

Independent research

Previous hospitalisations

Usually like to remain on familiar medical ground

Explanation of clinical pattern?

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

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

Thank you! AskTheNeurologist.Com Author Anon

AskTheNeurologist.Com

Author Anon

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