Case 117

Basic Human Neuroanatomy

A Clinically Oriented Atlas

Case History #117

Date of Consultation: 8-4-1988

HISTORY OF PRESENT ILLNESS:

This 27-year-old right-handed white female secretary was referred for neurologic evaluation of left lower limb symptoms. The patient indicated that she was well without prior neurologic problems until she was involved in a motor vehicle accident 9 months prior to consultation. The accident was a freak accident in that she parked her car such that the driver's side of her car was very close to a truck. She got out of her car without turning the ignition off. Unfortunately, she forgot to shift the transmission out of drive, and the car started to move. The patient jumped back into her car to try to stop it as the car moved forward very close to the parked truck. Her car was so close to the truck that the open car door was forced closed while her left lower limb was still outside of the car. This pressed the car door firmly against her left lower limb at a point just below the left knee, and this compression was maintained while her car moved forward the full length of the truck. Since the accident, the patient experienced weakness of the left foot and ankle, especially ankle dorsiflexion, and instability of the left ankle. She also noticed numbness and tingling along the lateral aspect of the knee and anterolateral aspect of the leg. At times, disagreeable tingling and sharp, stabbing and shooting pains were present in the anterolateral aspect of the left leg, radiating down onto the dorsum of the foot.

NEUROLOGICAL EXAMINATION:

Mental Status Exam: Intact.

Cranial Nerves: Intact.

Motor System: Focal muscular atrophy and fasciculations were absent. Muscle tone was normal in all 4 limbs. Muscle power was normal in both upper limbs and the right lower limb. In the left lower limb, weakness was noted in dorsiflexion of the ankle, inversion and eversion of the foot, and extension or dorsiflexion of the toes. This weakness was moderate in degree (4/5). Plantar flexion of the ankle was normal (5/5), and more proximal muscle groups were also normal.

Reflexes: Intact

Sensory System: Sensory examination was normal except for the following. In the left lower limb, decreased appreciation of pinprick and light touch was present in the dorsum of the foot and the anterolateral aspect of the leg. In these areas, a disagreeable, exaggerated, unpleasant response was provoked by simple stimulation. Palpation along the posterior border of the biceps femoris tendon of insertion and around the neck of the fibula was extremely tender.

Cerebellar Function: Intact.

Gait and Stance: Regular gait was performed essentially normally, although the patient turned the left foot outward to compensate for weakness of dorsiflexion. She was unable to walk on her heels but could walk on her toes quite effectively. Tandem gait was normal. The Romberg test was negative

Questions

1. Does this patient's weakness suggest an upper motor neuron or lower motor neuron process?

2. This patient experienced a variety of abnormal sensory signs and symptoms. List the terms relating to these sensory phenomena, along with their definitions or descriptions.

3. Is there evidence of spinal cord involvement in this case and, if so, at what level?

4. Is there evidence of dorsal or ventral root involvement or spinal nerve involvement in this case, and, if so, what is the level(s) of the involvement?

5. Is there evidence of plexus or peripheral nerve involvement in this case? If so, indicate the specific structure(s) involved by the pathologic process.

6. Where is the anatomical location of the pathologic process leading to this patient’s condition?

7. In general, what type of pathological process do you think is involved in this case?

8. What diagnostic procedure(s) would you undertake at this point?

Answers