left upper limb weakness- Diagnosis?
An 16 years old male is having weakness of left upper limb with wasting over a period of last 6 months. Also gives history weaked grip of left hand . Apparently everything looks normal as no other symptoms What next should be done for further evaluation of this case
Very interesting case Important points to be noted in this case are 1) This patient has weakness in left upper limb and weakened grip of left hand 2) There is muscular wasting of left hand Muscules What do these finding tells us? It tells up that it is a disease affection motor nerves and sensory nerves are specifically spared Another important thing it tells us that it is a lower motor neurons are affected. In affection of lower motor neuron muscular wasting is observed, upper motor neuron affection results in stiffness of muscle. Because sensory nerves are not involved - few disease which cause muscle wasting and lower motor neuron affection are ruled out - these diseases are - Carpal tunnel syndrome, compression of nerves in cervical spine because of cervical spondylosis or disc prolapse, compression of nerves by cervical rib. Now what are differential diagnosis?? 1) Amyotrophic lateral sclerosis 2) Spinal muscular atrophy 3) Multiple sclerosis 4) Myasthenia Gravis Other condition which affect purely motor nerves - Guillian Barre syndrome is ruled out because - it is a rapidly progressive disease, starts with affection of lower limb and affect both sides symmetrically Investigation Nerve conduction study Electromyography MRI of brain and cervical spine They will further aid in confirming the diagnosis
Very interesting case Important points to be noted in this case are 1) This patient has weakness in left upper limb and weakened grip of left hand 2) There is muscular wasting of left hand Muscules What do these finding tells us? It tells up that it is a disease affection motor nerves and sensory nerves are specifically spared Another important thing it tells us that it is a lower motor neurons are affected. In affection of lower motor neuron muscular wasting is observed, upper motor neuron affection results in stiffness of muscle. Because sensory nerves are not involved - few disease which cause muscle wasting and lower motor neuron affection are ruled out - these diseases are - Carpal tunnel syndrome, compression of nerves in cervical spine because of cervical spondylosis or disc prolapse, compression of nerves by cervical rib. Now what are differential diagnosis?? 1) Amyotrophic lateral sclerosis 2) Spinal muscular atrophy 3) Multiple sclerosis 4) Myasthenia Gravis Other condition which affect purely motor nerves - Guillian Barre syndrome is ruled out because - it is a rapidly progressive disease, starts with affection of lower limb and affect both sides symmetrically Investigation Nerve conduction study Electromyography MRI of brain and cervical spine They will further aid in confirming the diagnosis
I thank all curofy doctors who gave opinions in this case with best possible explanations of diagnosis. Since it was a complex case for me to diagnose as patient has not been properly attended by neurologist and taken it to be a normal finding .I Thank Dr Jayesh and Dr Reddy as both are surgeons belonging to my specialty , but interest in other specialities as well - which as surgeon I think is a Healthy trend . I also thank Dr Krishnan Pichumani , Dr Mansukh Shah , Dr Sunil Yadav and Dr Bhushan Patil for their opinions in this case . After going through the above discussion- I agree with Dr.Nihar Ranjan Mohanty for his diagnosis as SUSPECTED MONOMELIC AMYOTROPHY ALSO CALLED HIRAYAMA DISEASE. I thank Dr Mohanty for giving me a clue for further evaluation. I will let my colleagues know what is the diagnosis as MRI scan of neck can diagnose Hirayama disease which is a benign lower motor neuron disease. THANKS
??? Thoracic outlet syndrome Compression of lower trunk of brachial plexus (ulnar nerve) by cervical rib. Pain along the medial side of forearm,arm , tingling sensation,wasting over the ulnar nerve supplying area. Investigations....Chest X ray, CT neck and thorax, Angiogram... Further Management depends on the reports ...either conservative /surgical approach.
Tendons on dorsal aspect of left hand are prominent, indicating interossrous wasting. Chronic ulnar nerve compression DD HANSENS Tardy ulnar palsy due to old elbow fracture Spinal pathology, like cervical spondylosis, canal stenosis, syringomylia
Investigation for weaknesses of lt upper limb check ulnar nerve thickened it is Henson's cervical lt rib syndrome dd brachail plexsus syndrome dd any pathology in rt brain do mri brain with spine with angio EMG upperlimb
Loss of power in unilateral upper limb with wasting of muscle Lower motor neuron disease Likely thoracic outlet syndrome 2 cervical rib syndrome 3 brachial plexus compression
* Brachial Plexus conduction affecting muscle power ** Blood supply partial obstruction to hand Cerebral condition effecting function of lt hand *Monomelic Amyotrophy Needs MRI brain ,nerve conduction,dopplar test to conclude.
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Nerve conduction study first If not conclusive,MRI cervical spine Opinion of a neurologist before proceeding
D/D:- 1)Carpel tunnel syndrome 2) ulnar neuropathy 3) Saturday Night palsy Adv:- 1)Nerve Conduction Study 2) CT cervical region T/T:- 1) anti-inflammatory medication along with muscle relaxant. 2) Physiotherapy 3) body massage with बला तैल helpful.
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42 years female complaining of pain in right forearm since 5months . unable to do house hold work . visible waisting of muscles seen .suggest diagnosis n treatment @Dr. Ramanujam Maurya
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What is foot drop Foot drop is a gait abnormality in which the dropping of the forefoot happens due to weakness, irritation or damage to the common fibular nerve including the sciatic nerve, or paralysis of the muscles in the anterior portion of the lower leg. It is usually a symptom of a greater problem, not a disease in itself. Foot drop is characterized by inability or impaired ability to raise the toes or raise the foot from the ankle (dorsiflexion). Foot drop may be temporary or permanent, depending on the extent of muscle weakness or paralysis and it can occur in one or both feet. In walking, the raised leg is slightly bent at the knee to prevent the foot from dragging along the ground. Foot drop can be caused by nerve damage alone or by muscle or spinal cord trauma, abnormal anatomy, toxins, or disease. Toxins include organophosphate compounds which have been used as pesticides and as chemical agents in warfare. The poison can lead to further damage to the body such as a neurodegenerative disorder called organophosphorus induced delayed polyneuropathy. This disorder causes loss of function of the motor and sensory neural pathways. In this case, foot drop could be the result of paralysis due to neurological dysfunction. Diseases that can cause foot drop include trauma to the posterolateral neck of fibula, stroke, amyotrophic lateral sclerosis, muscular dystrophy, poliomyelitis, Charcot Marie Tooth disease, multiple sclerosis, cerebral palsy, hereditary spastic paraplegia, Guillain–Barré syndrome, and Friedreich's ataxia. It may also occur as a result of hip replacement surgery or knee ligament reconstruction surgery. Signs and symptom Human lower leg anatomy Foot drop is characterized by steppage gait.[1]While walking, people suffering the condition drag their toes along the ground or bend their knees to lift their foot higher than usual to avoid the dragging.[2] This serves to raise the foot high enough to prevent the toe from dragging and prevents the slapping.[3][4] To accommodate the toe drop, the patient may use a characteristic tiptoe walk on the opposite leg, raising the thigh excessively, as if walking upstairs, while letting the toe drop. Other gaits such as a wide outward leg swing (to avoid lifting the thigh excessively or to turn corners in the opposite direction of the affected limb) may also indicate foot drop.[5] Patients with painful disorders of sensation (dysesthesia) of the soles of the feet may have a similar gait but do not have foot drop. Because of the extreme pain evoked by even the slightest pressure on the feet, the patient walks as if walking barefoot on hot sand. Pathophysiology The causes of foot drop, as for all causes of neurological lesions, should be approached using a localization-focused approach before etiologies are considered. Most of the time, foot drop is the result of neurological disorder; only rarely is the muscle diseased or nonfunctional. The source for the neurological impairment can be central (spinal cord or brain) or peripheral (nerves located connecting from the spinal cord to an end-site muscle or sensory receptor). Foot drop is rarely the result of a pathology involving the muscles or bones that make up the lower leg. The anterior tibialis is the muscle that picks up the foot. Although the anterior tibialis plays a major role in dorsiflexion, it is assisted by the fibularis tertius, extensor digitorum longus and the extensor halluces longus. If the drop foot is caused by neurological disorder all of these muscles could be affected because they are all innervated by the deep fibular (peroneal) nerve, which branches from the sciatic nerve. The sciatic nerve exits the lumbar plexus with its root arising from the fifth lumbar nerve space. Occasionally, spasticity in the muscles opposite the anterior tibialis, the gastrocnemius and soleus, exists in the presence of foot drop, making the pathology much more complex than foot drop. Isolated foot drop is usually a flaccid condition. There are gradations of weakness that can be seen with foot drop, as follows: 0=complete paralysis, 1=flicker of contraction, 2=contraction with gravity eliminated alone, 3=contraction against gravity alone, 4=contraction against gravity and some resistance, and 5=contraction against powerful resistance (normal power). Foot drop is different from foot slap, which is the audible slapping of the foot to the floor with each step that occurs when the foot first hits the floor on each step, although they often are concurrent. Treated systematically, possible lesion sites causing foot drop include (going from peripheral to central): Neuromuscular disease;Peroneal nerve (common, i.e., frequent) —chemical, mechanical, disease;Sciatic nerve—direct trauma, iatrogenic;Lumbosacral plexus;L5 nerve root (common, especially in association with pain in back radiating down leg);Cauda equina syndrome, which is cause by impingement of the nerve roots within the spinal canal distal to the end of the spinal cord;Spinal cord (rarely causes isolated foot drop) —poliomyelitis, tumor;Brain (uncommon, but often overlooked) —stroke, TIA, tumor;Genetic (as in Charcot-Marie-Tooth Diseaseand hereditary neuropathy with liability to pressure palsies);Nonorganic causes. If the L5 nerve root is involved, the most common cause is a herniated disc. Other causes of foot drop are diabetes (due to generalized peripheral neuropathy), trauma, motor neuron disease (MND), adverse reaction to a drug or alcohol, and multiple sclerosis. Gait cycle Drop foot and foot drop are interchangeable terms that describe an abnormal neuromuscular disorder that affects the patient's ability to raise their foot at the ankle. Drop foot is further characterized by an inability to point the toes toward the body (dorsiflexion) or move the foot at the ankle inward or outward. Therefore, the normal gait cycle is affected by the drop foot syndrome. The normal gait cycle is as follows: Swing phase (SW): The period of time when the foot is not in contact with the ground. In those cases where the foot never leaves the ground (foot drag), it can be defined as the phase when all portions of the foot are in forward motion.Initial contact (IC): The point in the gait cycle when the foot initially makes contact with the ground; this represents the beginning of the stance phase. It is suggested that heel strike not be a term used in clinical gait analysis as in many circumstances initial contact is not made with the heel. Suggestion: Should use foot strike.Terminal contact (TC): The point in the gait cycle when the foot leaves the ground: this represents the end of the stance phase or beginning of the swing phase. Also referred to as foot off. Toe-off should not be used in situations where the toe is not the last part of the foot to leave the ground. The drop foot gait cycle requires more exaggerated phases. Drop foot SW: If the foot in motion happens to be the affected foot, there will be greater flexion at the knee to accommodate the inability to dorsiflex. This increase in knee flexion will cause a stair-climbing movement.Drop foot IC: Initial contact of the foot that is in motion will not have normal heel-toe foot strike. Instead, the foot may either slap the ground or the entire foot may be planted on the ground all at once.Drop foot TC: Terminal contact that is observed in patients that have drop foot is quite different. Since patients tend to have weakness in the affected foot, they may not have the ability to support their body weight. Often, a walker or cane will be used to assist in this aspect. Drop Foot is the inability to dorsiflex, evert, or invert the foot. So when looking at the Gait cycle, the part of the gait cycle that involves most dorsiflexion action would be Heel Contact of the foot at 10% of Gait Cycle, and the entire swing phase, or 60-100% of the Gait Cycle. This is also known as Gait Abnormalities. DiagnosisEdit Initial diagnosis often is made during routine physical examination. Such diagnosis can be confirmed by a medical professional such as a neurologist, orthopedic surgeon or neurosurgeon. A person with foot drop will have difficulty walking on his or her heels because he will be unable to lift the front of the foot (balls and toes) off the ground. Therefore, a simple test of asking the patient to dorsiflex may determine diagnosis of the problem. This is measured on a 0-5 scale that observes mobility. The lowest point, 0, will determine complete paralysis and the highest point, 5, will determine complete mobility. There are other tests that may help determine the underlying etiology for this diagnosis. Such tests may include MRI, MRN, or EMG to assess the surrounding areas of damaged nerves and the damaged nerves themselves, respectively. The nerve that communicates to the muscles that lift the foot is the peroneal nerve. This nerve innervates the anterior muscles of the leg that are used during dorsi flexion of the ankle. The muscles that are used in plantar flexion are innervated by the tibial nerve and often develop tightness in the presence of foot drop. The muscles that keep the ankle from supination (as from an ankle sprain) are also innervated by the peroneal nerve, and it is not uncommon to find weakness in this area as well. Paraesthesia in the lower leg, particularly on the top of the foot and ankle, also can accompany foot drop, although it is not in all instances. A common yoga kneeling exercise, the Varjrasana has, under the name "yoga foot drop," been linked to foot drop. Vajrasana yoga foot drop --- Yoga foot drop is a kind of drop foot, a gait abnormality. It is caused by a prolonged sitting on heels, a common yoga position of vajrasana. The name was suggested by Joseph Chusid, MD, in 1971, who reported a case of foot drop in a student who complained about increasing difficulty to walk, run, or climb stairs. The cause was thought to be injury to the common peroneal nerve, which is compressed and thereby deprived of blood flow while kneeling. Yoga foot drop is a potential adverse effect of yoga, allegedly unmentioned by yoga teachers and books
Dr. Rina Upadhyay9 Likes15 Answers - Login to View the image
50 yrs male Complaints of gradual weakness and muscle wasting of both upper limbs Expert opinion please doctors
Dr. Babu Seemairajan2 Likes14 Answers - Login to View the image
THORACIC OUTLET SYNDROME ( T O S ) Thoracic outlet syndrome (TOS) is a condition whereby symptoms are produced (such as numbness in fingers, pain in shoulder, arm, and neck) due to compression of nerves and/or blood vessels in the upper chest. The passageway for these nerves and blood vessels to exit the chest and supply the upper extremities is referred to as the thoracic outlet. Muscle, bone, and other tissues border the thoracic outlet. Any condition that results in enlargement or movement of these tissues of or near the thoracic outlet can cause the thoracic outlet syndrome. These conditions include muscle enlargement (such as from weight lifting), injuries, an extra rib extending from the neck (cervical rib), weight gain, and rare tumors at the top of the lung. Often no specific cause is detectable. Risk factors include occupations that involve heavy usage of the upper extremities against resistance, including jack-hammer operators and dental hygienists, weight lifting, pregnancy, and obesity. Any condition that causes encroachment of the space for the brachial plexus at the thoracic outlet can lead to thoracic outlet syndrome, including poor posture. Symptoms include neck, shoulder, and arm pain, numbness in the fingers, or impaired circulation and flushed sensations to the extremities (causing discoloration). The involved upper extremity can feel weak. Often symptoms are reproduced or worsened when the arm is positioned above the shoulder or extended. Patients can have a wide spectrum of symptoms from mild and intermittent to severe and constant. Pains can extend to the fingers and hands, causing weakness. The diagnosis of thoracic outlet syndrome is suggested by the symptoms and supported by findings of the doctor during the examination. Certain maneuvers of the arm and neck can produce symptoms and blood vessel "pinching," causing a loss of pulse. This includes the Adson's maneuver, whereby the examiner moves the shoulder joint into positions that can cause pinching of both the nerves and artery to the tested arm. Differential Diagnosis : ■ Extra cervical rib or ligamentous (false) rib. ■ Pancoast tumor. ■ Brachial plexopathy – infective or traumatic. ■ Heart attack (le side). ■ Vertebral artery disease or aneurism. ■ Hyperkyphosis or scoliosis of the thoracic spine. ■ Neck degenerative changes, cervical bars and osteophytes. ■ Radial Neuropathy. ■ Syringomyelia. ■ Complex Regional Pain Syndrome 1(CRPS1) - RSD. ■ Problems (age related) with the neck including discs and spinal joints. ■ Ankylosing spondylitis. ■ Median neuropathy. ■ Ulnar neuropathy.
Dr. Girish Dahake8 Likes11 Answers
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