Diagnosis of Lower Extremity Paralysis
-
Upload
many87 -
Category
Health & Medicine
-
view
1.296 -
download
3
Transcript of Diagnosis of Lower Extremity Paralysis
![Page 1: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/1.jpg)
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
![Page 2: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/2.jpg)
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.
![Page 3: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/3.jpg)
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
![Page 4: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/4.jpg)
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
![Page 5: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/5.jpg)
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?
![Page 6: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/6.jpg)
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
![Page 7: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/7.jpg)
The NeuraxisThe Neuraxis
MuscleN-M
junctionNerve Plexus Root
Supra-Tent
PostFossa
CordAnt
HornCell
![Page 8: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/8.jpg)
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
![Page 9: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/9.jpg)
Where is the lesion?Where is the lesion?
Focal vs. Multifocal vs. DiffuseFocal vs. Multifocal vs. Diffuse
![Page 10: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/10.jpg)
What is the lesion?What is the lesion?
![Page 11: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/11.jpg)
What? Involves 2 QuestionsWhat? Involves 2 Questions
1. What is the temporal profile?1. What is the temporal profile?• OnsetOnset• EvolutionEvolution
![Page 12: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/12.jpg)
OnsetOnset
AcuteAcute--within minutes to hours--within minutes to hours SubacuteSubacute--within days--within days ChronicChronic--within months--within months
![Page 13: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/13.jpg)
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
![Page 14: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/14.jpg)
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.
![Page 15: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/15.jpg)
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
![Page 16: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/16.jpg)
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
![Page 17: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/17.jpg)
TTraumarauma
External traumaExternal trauma Compressive TraumaCompressive Trauma
![Page 18: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/18.jpg)
NNeoplasticeoplastic
Vertebral mets with cord Vertebral mets with cord compressioncompression
Intraspinal tumorIntraspinal tumor Leptomeningeal cancerLeptomeningeal cancer ParaneoplasticParaneoplastic
![Page 19: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/19.jpg)
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
![Page 20: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/20.jpg)
IInfectious/nfectious/IInflammatorynflammatory
VirusesViruses• HIVHIV• PolioPolio• HTLV-1HTLV-1• CMVCMV• West Nile/Japanese encephalitisWest Nile/Japanese encephalitis• RabiesRabies
![Page 21: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/21.jpg)
IInfectious/nfectious/IInflammatorynflammatory BacteriaBacteria
• BrucellaBrucella• SyphilisSyphilis• TBTB• LeprosyLeprosy• Any bacterial abscessAny bacterial abscess
HelminthsHelminths• SchistosomiasisSchistosomiasis
InflammatoryInflammatory• Guillain-BarreGuillain-Barre
![Page 22: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/22.jpg)
VVascularascular
Spinal Cord Infarct Spinal Cord Infarct Spinal AVMSpinal AVM VasculitisVasculitis
![Page 23: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/23.jpg)
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)
![Page 24: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/24.jpg)
Toxic/Toxic/MMetabolicetabolic
MetabolicMetabolic• DiabetesDiabetes
Meds/DrugsMeds/Drugs• EtOHEtOH• HAARTHAART• INHINH• ChloroquineChloroquine• MetronidazoleMetronidazole• NitrofurantoinNitrofurantoin
![Page 25: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/25.jpg)
Toxic/Toxic/MMetabolicetabolic
ToxinsToxins• ArsenicArsenic• LeadLead• ThalliumThallium• OrganophosphatesOrganophosphates• TOCPTOCP• MethanolMethanol• Plant PoisonsPlant Poisons• CiguateraCiguatera
![Page 26: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/26.jpg)
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
![Page 27: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/27.jpg)
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
![Page 28: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/28.jpg)
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.
![Page 29: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/29.jpg)
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
![Page 30: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/30.jpg)
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
![Page 31: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/31.jpg)
Pott’s diseasePott’s disease
![Page 32: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/32.jpg)
Pott’s diseasePott’s disease
![Page 33: Diagnosis of Lower Extremity Paralysis](https://reader036.fdocuments.us/reader036/viewer/2022062319/556b878fd8b42a6c7c8b4faa/html5/thumbnails/33.jpg)