Workup question

[Timeoutofmind]

Pain doc here.

Was curious how you guys would approach this:

Pt has new onset RLE pain, with neuropathic descriptors, anteriorly down the leg, all the way to the sole of the foot.

History of neotofibromatosis type 1.

Had L spine MRI before seeing me, unremarkable.

When I examine, strength and sensory intact. Babinski normal. All reflexes normal, except the right patellar is strongly hyper-reflexic. (I had examined him several months ago, prior to this leg pain, and reflexes were normal).

I am wondering if this is myelopathy.

Here is my question. The issue could be in the T or the C spine. I was thinking that given his normal upper extremity exam, would start with T spine imaging. Or would you just order both right away? Anything else you would order off the bat?

Thanks in advance.

---

Members don't see this ad.

 

[neglect]

@Timeoutofmind

Highly unlikely for dermatomal distribution of pain to be referable to the spine. Seems just a root lesion and neg MRI, common enough.

It is very fair to WU neurofibromas with total spine imaging given hyper-reflexia. But if this is ONLY causing hyper-reflexia, kinda back to square one.

 

[deathmerchant]

Pain doc here.

Was curious how you guys would approach this:

Pt has new onset RLE pain, with neuropathic descriptors, anteriorly down the leg, all the way to the sole of the foot.

History of neotofibromatosis type 1.

Had L spine MRI before seeing me, unremarkable.

When I examine, strength and sensory intact. Babinski normal. All reflexes normal, except the right patellar is strongly hyper-reflexic. (I had examined him several months ago, prior to this leg pain, and reflexes were normal).

I am wondering if this is myelopathy.

Here is my question. The issue could be in the T or the C spine. I was thinking that given his normal upper extremity exam, would start with T spine imaging. Or would you just order both right away? Anything else you would order off the bat?

Thanks in advance.

Consider adding EMG/NCS.

 

[Algor]

Here is my 2c.
The pain and sensation are highly subjective. But reflexes, if done properly, are very objective. So, there could be several explanations. The patient takes too much SSRI and has hyperreflexia, maybe he has chronic radiculopathy on the left and that is why hyporeflexic there. However, if you are convinced there is hyperreflexia in his ankle only, I would do MRI of C/T spine and brain. Babinski is always a strong sign of upper motor neuron damage. If you are convinced there is no Babinski, it makes upper motor neuron lesion less likely, but does not rule it out.