diagnosis of lower extremity paralysis
TRANSCRIPT
Diagnosis of Lower Diagnosis of Lower Extremity ParalysisExtremity Paralysis
James H. Bower, MD, MSc, DTMHJames H. Bower, MD, MSc, DTMH
Mayo ClinicMayo Clinic
Rochester, MN USARochester, MN USA
Case StudyCase Study
A twenty year old man presents A twenty year old man presents complaining of worsening gait complaining of worsening gait difficulty over the last week. He also difficulty over the last week. He also has had six months of back pain. On has had six months of back pain. On ROS, he describes intermittent ROS, he describes intermittent feverishness, malaise and a 20 feverishness, malaise and a 20 pound weight loss. pound weight loss.
Case StudyCase Study
On Exam:On Exam:• Moderate weakness of the bilateral hip Moderate weakness of the bilateral hip
flexors, knee flexors, and ankle flexors, knee flexors, and ankle dorsiflexorsdorsiflexors
• Brisk knee and ankle reflexesBrisk knee and ankle reflexes• A sensory level around T-10A sensory level around T-10• A bony deformity in his lower spineA bony deformity in his lower spine
The most likely diagnosis is:The most likely diagnosis is:
A. B. C. D. E.
23%
50%
0%
10%
17%
A.A. Neoplastic spinal cord Neoplastic spinal cord compressioncompression
B.B. TBTB
C.C. PolioPolio
D.D. HIV myelopathyHIV myelopathy
E.E. LeprosyLeprosy
Two QuestionsTwo Questions
1. Where is the lesion located?1. Where is the lesion located?
2. What is the lesion?2. What is the lesion?
Where is the Lesion?Where is the Lesion?
Requires understanding of functional Requires understanding of functional neuroanatomyneuroanatomy
Neurological exam is the prime Neurological exam is the prime determinantdeterminant
The NeuraxisThe Neuraxis
MuscleN-M
junctionNerve Plexus Root
Supra-Tent
PostFossa
CordAnt
HornCell
MuscleMuscle NerveNerve Root/Root/
PlexusPlexusAnt Ant Horn Horn CellCell
CordCord
MotorMotor Proximal Proximal MusclesMuscles
Distal Distal MusclesMuscles
VariableVariable VariableVariable Hip, Knee, Hip, Knee, ankle ankle FlexorsFlexors
SensorySensory NormalNormal Distal Distal lossloss
VariableVariable NormalNormal Sensory Sensory LevelLevel
ReflexesReflexes Normal to Normal to
decreaseddecreased
DecreasedDecreased DecreasedDecreased DecreasedDecreased IncreasedIncreased
ToneTone NormalNormal NormalNormal FlaccidFlaccid FlaccidFlaccid SpasticSpastic
Where is the lesion?Where is the lesion?
Focal vs. Multifocal vs. DiffuseFocal vs. Multifocal vs. Diffuse
What is the lesion?What is the lesion?
What? Involves 2 QuestionsWhat? Involves 2 Questions
1. What is the temporal profile?1. What is the temporal profile?• OnsetOnset• EvolutionEvolution
OnsetOnset
AcuteAcute--within minutes to hours--within minutes to hours SubacuteSubacute--within days--within days ChronicChronic--within months--within months
EvolutionEvolution Transient Transient -- Temporary symptoms that Temporary symptoms that
have resolved completelyhave resolved completely ImprovingImproving - Symptoms that show - Symptoms that show
evidence of partial resolutionevidence of partial resolution ProgressiveProgressive - Symptoms which continue - Symptoms which continue
to increase in severity, or show new to increase in severity, or show new symptomssymptoms
StationaryStationary - Symptoms which have - Symptoms which have reached maximum severity and have reached maximum severity and have shown no significant changeshown no significant change
What? Involves 2 QuestionsWhat? Involves 2 Questions
2. What is the most likely etiology?2. What is the most likely etiology?
The neurologic The neurologic differential is very differential is very
manageable.manageable.
The neurologic differential is The neurologic differential is very manageable.very manageable.
TThehe TraumaTrauma NNeurologiceurologic NeoplasticNeoplastic DDifferentialifferential Degenerative/Demyelinating/Degenerative/Demyelinating/
DevelopmentalDevelopmental
IIss Infectious/Infectious/
InflammatoryInflammatory VVeryery VascularVascular MManageableanageable Toxic/MetabolicToxic/Metabolic
Important Temporal and Important Temporal and Spatial FeaturesSpatial Features
ACUTEACUTE SUBACUTESUBACUTE CHRONICCHRONIC
FOCALFOCAL VascularVascular
TraumaTraumaInflammatory/Inflammatory/InfectiousInfectious
NeoplasmNeoplasm
DIFFUSEDIFFUSE VascularVascular
TraumaTrauma
Toxic/MetabToxic/Metab
Inflammatory/Inflammatory/InfectiousInfectious
Toxic/MetabToxic/Metab
DegenerativeDegenerative
Toxic/MetabToxic/Metab
TTraumarauma
External traumaExternal trauma Compressive TraumaCompressive Trauma
NNeoplasticeoplastic
Vertebral mets with cord Vertebral mets with cord compressioncompression
Intraspinal tumorIntraspinal tumor Leptomeningeal cancerLeptomeningeal cancer ParaneoplasticParaneoplastic
DDegenerative/egenerative/DDemyelinating/emyelinating/DDevelopmentalevelopmental
Motor Neuron DiseaseMotor Neuron Disease Hereditary spastic paraparesisHereditary spastic paraparesis SyrinxSyrinx Degenerative disc disease/ Degenerative disc disease/
spondylosisspondylosis Multiple SclerosisMultiple Sclerosis Devic’s diseaseDevic’s disease
IInfectious/nfectious/IInflammatorynflammatory
VirusesViruses• HIVHIV• PolioPolio• HTLV-1HTLV-1• CMVCMV• West Nile/Japanese encephalitisWest Nile/Japanese encephalitis• RabiesRabies
IInfectious/nfectious/IInflammatorynflammatory BacteriaBacteria
• BrucellaBrucella• SyphilisSyphilis• TBTB• LeprosyLeprosy• Any bacterial abscessAny bacterial abscess
HelminthsHelminths• SchistosomiasisSchistosomiasis
InflammatoryInflammatory• Guillain-BarreGuillain-Barre
VVascularascular
Spinal Cord Infarct Spinal Cord Infarct Spinal AVMSpinal AVM VasculitisVasculitis
Toxic/Toxic/MMetabolicetabolic
NutritionalNutritional• B1 (Thiamine)B1 (Thiamine)• B6 (Pyridoxine)B6 (Pyridoxine)• B12B12• Vit EVit E• Cassava (konzo)Cassava (konzo)• Chick pea (Lathyrism)Chick pea (Lathyrism)
Toxic/Toxic/MMetabolicetabolic
MetabolicMetabolic• DiabetesDiabetes
Meds/DrugsMeds/Drugs• EtOHEtOH• HAARTHAART• INHINH• ChloroquineChloroquine• MetronidazoleMetronidazole• NitrofurantoinNitrofurantoin
Toxic/Toxic/MMetabolicetabolic
ToxinsToxins• ArsenicArsenic• LeadLead• ThalliumThallium• OrganophosphatesOrganophosphates• TOCPTOCP• MethanolMethanol• Plant PoisonsPlant Poisons• CiguateraCiguatera
Work-UpWork-Up
HistoryHistory• Temporal profileTemporal profile• Sensory or Bowel/Bladder deficits?Sensory or Bowel/Bladder deficits?• Nutritional historyNutritional history
Neuro ExamNeuro Exam• Motor- UMN vs. radicular vs. distalMotor- UMN vs. radicular vs. distal• Sensory- Sensory level vs. dermatomal Sensory- Sensory level vs. dermatomal
vs. distalvs. distal• Reflexes- Hyper or hyporeflexiveReflexes- Hyper or hyporeflexive
Work-UpWork-Up General ExamGeneral Exam
• Chest for TBChest for TB• Abd for ShistoAbd for Shisto• Back for gibbus, trauma, bacterial abscessBack for gibbus, trauma, bacterial abscess
Ancillary considerationsAncillary considerations• HIVHIV• CXRCXR• Spine X-raySpine X-ray• ESRESR• Urine for RBC’sUrine for RBC’s
Case StudyCase Study
A twenty year old man presents A twenty year old man presents complaining of worsening gait complaining of worsening gait difficulty over the last week. He also difficulty over the last week. He also has had six months of back pain. On has had six months of back pain. On ROS, he describes intermittent ROS, he describes intermittent feverishness, malaise and a 20 feverishness, malaise and a 20 pound weight loss. pound weight loss.
Case StudyCase Study
On Exam:On Exam:• Moderate weakness of the bilateral hip Moderate weakness of the bilateral hip
flexors, knee flexors, and ankle flexors, knee flexors, and ankle dorsiflexorsdorsiflexors
• Brisk knee and ankle reflexesBrisk knee and ankle reflexes• A sensory level around T-10A sensory level around T-10• A bony deformity in his lower spineA bony deformity in his lower spine
Case StudyCase Study
The most likely diagnosis is:The most likely diagnosis is:
A. Neoplastic spinal cord compressionA. Neoplastic spinal cord compression
B. TBB. TBC. PolioC. Polio
D. HIV myelopathyD. HIV myelopathy
E. LeprosyE. Leprosy
Pott’s diseasePott’s disease
Pott’s diseasePott’s disease
