Case History #149

Date of Consultation: 4-7-2008

HISTORY OF PRESENT ILLNESS:

This 34-year-old right-handed Caucasian female was referred for neurologic consultation to evaluate her ongoing neurologic deficits.  Approximately two years prior to consultation, the patient was involved in a motor vehicle accident.  Following that accident, she was noted to have weakness and sensory findings in all four limbs.  Evaluation at that time revealed herniated discs in the cervical region of the vertebral column.  She underwent neurosurgical treatment of the herniated discs.  Following the surgery, she made a moderate recovery with rehabilitation. 

NEUROLOGICAL EXAMINATION:

Mental Status Exam:  Intact.

Cranial Nerves:  Intact.

Motor System:  There were no areas of focal or generalized muscular atrophy.  There were no fasciculations.  Muscle tone was normal on the right side of the body.  On the left, her muscle tone was increased, especially in the left hand and forearm muscles and in the left lower limb.  Muscle power testing was normal on the right.  In the left upper limb, muscle power was rated at 4+/5, although the intrinsic hand muscles and finger extensors were somewhat weaker.  In the left lower limb, her weakness was rated at 4/5 diffusely.  Rapid repetitive movements were slow in the left hand.

Reflexes:  Deep tendon reflexes were brisker on the left than the right, especially in the left lower limb.  Plantar reflexes were flexor on the right and extensor on the left. 

Sensory System:  The patient perceived joint position sense in all 4 limbs, although it appeared to be less well perceived in the left fingers and toes than on the right.  There was decreased appreciation of pinprick and temperature on the right side of the body involving the right upper and lower limbs and the right side of the trunk up to the clavicle.  Above the level of the clavicle, sensations were symmetric.

Cerebellar Function:  The patient performed cerebellar tests normally. 

Gait and Stance:  Regular gait was performed with slight circumduction of the left lower limb.  However, the patient was able to perform tandem gait.  The Romberg test was negative.

Questions:

1.  Is the patient’s left-sided weakness suggestive of an upper motor neuron or lower motor neuron process?

2.  Indicate the specific structures involved by the pathologic process to produce this patient’s left-sided weakness, increased muscle tone, hyperreflexia, and extensor plantar reflex.   

3.  What sensory pathway is involved to produce this patient’s pain and temperature deficit?

4.  What sensory pathways are involved to produce this patient’s mild joint position sense (conscious proprioception) deficits?

5.  Indicate the anatomical location of the pathologic process in this case.   

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

7.  This patient’s clinical signs and symptoms constitute a classic neurologic syndrome.  What is the name of that syndrome? 

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