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 Post subject: Neurology / Neurosurgery
PostPosted: 12 Oct 2014 01:11 
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Joined: 20 Jul 2013 17:30
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I am a 73 yrs old semi retired doctor. Active in General Practice since 2012 .
Summary of problem.
Returned from a hectic holiday to Phuket n Malaysia in Jan 2012 when I noticed weakness of my R Leg and slight loss of balance.After exhaustive tests n investigations was found to have a Neurofibroma which was removed on the 6 March 2012 it was benign
Now 2years n 9months later I have made slow recovery.
My problem now is marked paraesthesia of both my legs esp at night or when lying down
Low backache due to Lumbar Spondylolithesis L4 / L5 from grade 1 to grade 2 over a period of 1 Year
Slight loss of balance as per Rhomberg's sign
I have been on Neurontin, Lyrica , Trepiline.. for the Paraesthesia. No help also because of side effects.
Cannot take Anti- inflammatories because I am on Warfarin ( have atrial fibrillation )
What is your impression n provisional diagnosis. I am not a Diabetic.
Could it be.due to .....Upper motor neuron lesion
Lower motor neuron lesion
Mixed upper n lower motor neuron lesion
Lumbar Spondylolithesis L4 / L5 Grade 1 to Grade 2
Lumbar spinal stenosis L 2 to L 5
Or complications following the removal of the Neurofibroma
Kindly brain storm my problem n advice
Much appreciated
Dr Duray Charles


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PostPosted: 14 Oct 2014 02:40 
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Hello dear Charles,

Good to hear from you.
Allow me to examine you for starters , as you have allready given us a good history.
The following is useful to all of us as basics.

Examination of the motor system

Inspection
Note the resting posture. Is there unusual rotation or posture of a joint? Is the patient symmetrical?
Look for muscle wasting or hypertrophy: is it focal or diffuse?
Look for involuntary movements such as tremor, tics, myoclonic jerks, chorea or athetosis.
Look for muscle fasciculation (a sign of lower motor neurone disease process). These are subcutaneous twitches over a muscle belly at rest. Tapping the belly may stimulate fasciculation.



Tone
Tone is the resistance felt when a joint is moved passively through its normal range of movement.
Hypertonia is found in upper motor neurone lesions; hypotonia is found in lower motor neurone lesions and cerebellar disorders.
Clonus is rhythmic and involuntary muscle contraction that can be provoked by stretching a group of muscles.

Test tone:
Ask the patient to let their legs 'go floppy'.
Internally and externally rotate the 'floppy' leg. Assess for any increased or reduced tone.
Then lift the knee off the bed with one of your hands. Does the ankle raise off the bed as well signifying increased tone?

Test for ankle clonus:
Flex the patient's knee, resting the ankle on the bed.
Dorsiflex the foot quickly and keep the pressure applied.
You will be able to see the foot moving up and down if clonus is present.

Power

A robust assessment of power is required.
The Medical Research Council (MRC) has a recommended grading system for power (see table).
Get the patient to contract the muscle group being tested and then you as the examiner try to overpower that group.

Test the following:
Hip flexion, extension, adduction and abduction.
Knee flexion and extension.
Foot dorsiflexion, plantar flexion, eversion and inversion.
Toe plantar flexion and dorsiflexion.
MRC scale for muscle power
0 No muscle contraction is visible.
1 Muscle contraction is visible but there is no movement of the joint.
2 Active joint movement is possible with gravity eliminated.
3 Movement can overcome gravity but not resistance from the examiner.
4 The muscle group can overcome gravity and move against some resistance from the examiner.
5 Full and normal power against resistance.

Deep tendon reflexes
Ensure that the patient is comfortable and relaxed and that you can see the muscle being tested.
Use a tendon hammer to strike the tendon of the muscle and look for muscle contraction.
Compare both sides.
Reflexes can be hyperactive (+++), normal (++), sluggish (+) or absent (-). ± is used when the reflex is only present on reinforcement (see below).

In the lower limbs:
Test the knee jerk (L3, L4): flex the patient's knee and support it by using one of your hands in their popliteal fossa. Elicit the reflex by tapping just below the patella.
Test the ankle jerk (S1): with the patient lying down, flex their knee and dorsiflex their ankle, at the same time rotating their leg slightly laterally. Elicit the reflex by tapping over the Achilles tendon just above the heel. If this is difficult to elicit, an alternative method is to ask the patient to kneel on a chair, facing the back of the chair, so that their feet are dangling off the seat of the chair. Tap over the same area in this position.
If a reflex is difficult to elicit, try 'reinforcement' (the Jendrassik manoeuvre). Ask the patient to flex their fingers and interlock them with one palm facing upwards and the other facing downwards. Then ask them to try to pull their fingers apart just before you strike the tendon.

Interpretation:

Upper motor neurone lesions usually produce hyperreflexia.
Lower motor neurone lesions usually produce a diminished or absent response.
It may be normal to have reduced or absent ankle reflexes in some elderly people, although the frequency and significance of this is disputed.
Isolated loss of a reflex can point to a radiculopathy affecting that segment, e.g loss of ankle jerk if there is an S1 disc prolapse.

In the lower limbs, this is the plantar response.
To elicit this, the patient should be lying down with their legs extended.
Use a blunted point and run this along the lateral border of the foot, starting at the heel and moving towards the big toe.
Stop on the first movement of the big toe.
An extensor plantar response (upgoing big toe) is pathological and signifies an upper motor neurone lesion.

Examination of co-ordination
The cerebellum helps in the co-ordination of voluntary, automatic and reflex movement. Tests of cerebellar function in the lower limbs include:
The heel-shin test:
Ask the patient to lift one of their legs and flex it at the knee, keeping the other leg straight.
They should then place the heel of the flexed leg on the knee of the other leg and run it down the shin towards the ankle and back again towards the knee.
Ask them to repeat this a number of times.

The heel-toe test:
This tests balance mechanisms that rely on the cerebellar, vestibular and proprioceptive systems.
The patient either needs to be barefoot or wearing flat shoes.
They should walk in a straight line so that the heel of the second foot touches the toes of the first foot. This should be repeated so that the heel of the first foot then touches the toes of the second foot etc., each time with the patient moving forward.
Look at how well they are able to perform this. Is there any staggering which would suggest a lesion of the cerebellum?

Romberg's test:
This also tests balance mechanisms that rely on the cerebellar, vestibular and proprioceptive systems.
Ask the patient to keep their eyes open and stand with their feet together, arms by their sides.
Then ask them to maintain this position when they close their eyes.

Patients who have cerebellar lesions often cannot stand in this position, even with their eyes open. If balance is only lost when the eyes are closed, this signifies a proprioceptive or vestibular lesion.
Be ready to catch the patient by standing behind.

Examination of gait
No neurological examination, especially of the lower limbs, is complete without observing gait.

Also, watch the patient as he or she rises from the chair to walk and note any abnormality of moovement.

I am sure you doctor would have checked all this , and you can tell us the findings.

Surely we can find a way forward.

G Mohan.


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PostPosted: 19 Oct 2014 23:52 
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Joined: 26 Feb 2013 10:59
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Dear Charles,

Mohan has written a detailed account of clinical examination of the nervous system for someone with a neurological problem involving the lower extremity. I am sure you have gone through all this. It would be good if you can give us the full picture as he has suggested. I feel in addition to the clinical findings detailed history prior to your surgery and following your back surgery would help us to analyse the problem fully.

Before your holiday in Phuket did you have any significant back problem (or in the past). Have you had any sensory or motor changes before surgery. Did you have any paresthesia before surgery. Soon after surgery did you have any motor weakness or sensory loss. Did the paresthesia come on immediately after surgery?

I remember you had Bell's palsy before your back problem. Did your physician give you the exact cause for that? Did you have any auditory nerve symptoms prior to that?

I would also like to know more about your surgery. You mentioned that it was a neurofibromatos mass that was excised from your spine. What exact level was the mass excised from? Did the pathologist tell you the type of neurofibroma that you had (Type 1 (NF1), Type 2 (NF2) or Schwannomatosis). I presume it was type 2 extramedullary but intradural tumour. Did the surgeon tell you the layer of the spinal nerve or cord where the tumour was attached?

Once we have all the details I shall try and get a neurologist's opinion as to how we should proceed .

Badri.


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PostPosted: 20 Oct 2014 02:30 
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Thanks Badri
I have replied to Mohan's email but can't seem to get it to him. However will answer all your questions .
Will be hearing from me shortly
Kind regards
Chil


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PostPosted: 21 Oct 2014 04:18 
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Dear Charles,
do send your replies thro the forum , as all members can read it and be able to offer informed views .

Best wishes.

Mohan.


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