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I saw a great case today and wanted to share in the form of an educational discussion. I'd like to see some residents do some cogitating on this one.
59 yo male referred for left lower leg numbness - anterolateral from the knee to the ankle, none in the foot. No pain in either leg. He has a 10 year Hx of proximal LE weakness, progressive to the point he might have to leave his factory job due to fatigue of walking and standing 8 - 12 hours per day. No Hx of LE or back injury. No surgeries. Only meds are HCTZ, and diclofenac for chronic sholder impingment. Quit smoking 10 years ago with approx 30 pack-year Hx. Rarely drinks alcohol. Non-diabetic. No family Hx neuro DO or similar symptoms.
PE shows atrophy of the quads bilaterally, normal to above normal muscle bulk of the shins and calves, except atrophy noted from about 2 inches above the malleoli and distal bilaterally. Intrinsic foot atrophy also noted, except EDB's are still palpable. He has 4/5 strength in the hip flexors, hip abductors and adductors and knee flexors. He has 2/5 knee extensors. 5/5 ankle dorsi and plantar flexion, as well as inversion and eversion and great toe extension, 4+/5 short toe extension, 4/5 toe flexion. Reflexes are absent in the knees hamstrings and ankles. Sensation is anesthetic to soft touch and pinprick along the anterolateral let lower leg, but normal elsewhere in the BLE's, including the feet and toes. No fasciculations noted. Normal muscle tone except for the weakness - no UMN signs. He walks with a shortened gait, leaning back a little.
UE exam shows 4/5 strength to shoulder abduction and external rotation, 5/5 internal rotation, elbow flexors and extensors, wrist and finger flexion and extension. Sensation and reflexes are normal in the BUE's as well.
Neck and lower back exams are benign - no tenderness, full, pain-free ROM. No impingment signs, no neural tension signs. Mental status normal. CN exam normal. Speech normal.
EMG/NCS performed by myself today. Motor studies of the bilateral peroneal and tibial nerves were normal through the knees, peroneal studies at the ankle and above and below the knee, tibial at the ankle and knee. Normal distal latencies, amplitudes and CV's, although the peroneal amplitudes were 3.4 and 3.2 mV, normal is 3.0 and above - near the borderline.
F-waves of the same nerves were all normal in latency and variability. H-reflexes were delayed by about 5 ms bilaterally. Sensory nerves all non-responding - bilateral sural, peroneal, saphenous and tibials.
Needle exam showed the following: bilateral quads had significantly reduced insertional activity, 2+ small PSWs and fibs, minimal small MUAPs, about 3-4 different ones seen at maximal contraction, all polyphasic. Iliopsoas and gluteals showed better insertional activity and recruitment, but still mostly polyphasic with 1-2+ PSWs and fibs.
Left tibialis anterior showed normal IA, 1+ fibs and PSWs, slightly reduced recruitment, no polyphasia. Right tib ant and bilateral gastrocs showed normal IA, no fibs or PSWs, slightly reduced recruitment. Left peroneus longus showed scattered fibs, otherwise normal.
Bilateral EDB's showed decreased IA, no fibs or PSW's and normal recruitment, but 2+ polyphasia. Bilateral FDIP's showed decreased insertional activity, no fibs or PSWs and minimal recruitment, slightly polyphasic - about 1/3.
Lumbar paraspinals showed decreased insertional activity bilaterally middle and lower lumbar, with scattered fibs and PSW's, slightly more on the left side. Upper lumbar PS fairly normal.
I'm deliberately withholding the diagnosis for the 10 years of weakness. What would you diagnose at this point? What would your next step in either treatment or work-up be? Assume the weakness has not be adequetely diagnosed yet. What questions can I answer?
59 yo male referred for left lower leg numbness - anterolateral from the knee to the ankle, none in the foot. No pain in either leg. He has a 10 year Hx of proximal LE weakness, progressive to the point he might have to leave his factory job due to fatigue of walking and standing 8 - 12 hours per day. No Hx of LE or back injury. No surgeries. Only meds are HCTZ, and diclofenac for chronic sholder impingment. Quit smoking 10 years ago with approx 30 pack-year Hx. Rarely drinks alcohol. Non-diabetic. No family Hx neuro DO or similar symptoms.
PE shows atrophy of the quads bilaterally, normal to above normal muscle bulk of the shins and calves, except atrophy noted from about 2 inches above the malleoli and distal bilaterally. Intrinsic foot atrophy also noted, except EDB's are still palpable. He has 4/5 strength in the hip flexors, hip abductors and adductors and knee flexors. He has 2/5 knee extensors. 5/5 ankle dorsi and plantar flexion, as well as inversion and eversion and great toe extension, 4+/5 short toe extension, 4/5 toe flexion. Reflexes are absent in the knees hamstrings and ankles. Sensation is anesthetic to soft touch and pinprick along the anterolateral let lower leg, but normal elsewhere in the BLE's, including the feet and toes. No fasciculations noted. Normal muscle tone except for the weakness - no UMN signs. He walks with a shortened gait, leaning back a little.
UE exam shows 4/5 strength to shoulder abduction and external rotation, 5/5 internal rotation, elbow flexors and extensors, wrist and finger flexion and extension. Sensation and reflexes are normal in the BUE's as well.
Neck and lower back exams are benign - no tenderness, full, pain-free ROM. No impingment signs, no neural tension signs. Mental status normal. CN exam normal. Speech normal.
EMG/NCS performed by myself today. Motor studies of the bilateral peroneal and tibial nerves were normal through the knees, peroneal studies at the ankle and above and below the knee, tibial at the ankle and knee. Normal distal latencies, amplitudes and CV's, although the peroneal amplitudes were 3.4 and 3.2 mV, normal is 3.0 and above - near the borderline.
F-waves of the same nerves were all normal in latency and variability. H-reflexes were delayed by about 5 ms bilaterally. Sensory nerves all non-responding - bilateral sural, peroneal, saphenous and tibials.
Needle exam showed the following: bilateral quads had significantly reduced insertional activity, 2+ small PSWs and fibs, minimal small MUAPs, about 3-4 different ones seen at maximal contraction, all polyphasic. Iliopsoas and gluteals showed better insertional activity and recruitment, but still mostly polyphasic with 1-2+ PSWs and fibs.
Left tibialis anterior showed normal IA, 1+ fibs and PSWs, slightly reduced recruitment, no polyphasia. Right tib ant and bilateral gastrocs showed normal IA, no fibs or PSWs, slightly reduced recruitment. Left peroneus longus showed scattered fibs, otherwise normal.
Bilateral EDB's showed decreased IA, no fibs or PSW's and normal recruitment, but 2+ polyphasia. Bilateral FDIP's showed decreased insertional activity, no fibs or PSWs and minimal recruitment, slightly polyphasic - about 1/3.
Lumbar paraspinals showed decreased insertional activity bilaterally middle and lower lumbar, with scattered fibs and PSW's, slightly more on the left side. Upper lumbar PS fairly normal.
I'm deliberately withholding the diagnosis for the 10 years of weakness. What would you diagnose at this point? What would your next step in either treatment or work-up be? Assume the weakness has not be adequetely diagnosed yet. What questions can I answer?
