Basic Human Neuroanatomy
A Clinically Oriented Atlas 

Case History #200

Date of Consultation: 6-5-1986


This 52-year-old right-handed Asian female University Registrar was referred for neurologic evaluation because of right lower limb symptoms.  Approximately 1.5 to 2 years prior to consultation, the patient noted the gradual onset of a numb, thick feeling in the second, third, and fourth toes of the right foot.  Over a period of several months, she noted this sensation of numbness and thickness moving up the right lower limb into the anterior, posterior, and lateral aspects of the leg.  The sensation continued to ascend to eventually involve the lateral aspect of the thigh, buttock, and recently seemed to involve the posterior lumbar area up to about the mid-thoracic region as well.  Along with this heavy, thick feeling, the patient noted some difficulty appreciating painful stimuli in the right lower limb and right foot and on occasion had difficulty knowing the exact position of her right foot.  At times, she noted that she was dragging the right lower limb and felt that it was heavy and somewhat weak.  She noted that when walking she had a tendency to circumduct the right foot and at times felt that the right lower limb was stiff.  The overall course of this problem was one of a gradual progression over the past 1.5 to 2 years.

Mental Status Exam:  Intact.

Cranial Nerves:  Cranial nerve examination was normal.

Motor System:  There was no evidence of focal muscular atrophy or fasciculations.  Muscle tone was perhaps subtly increased in the right lower limb when compared to the left but was symmetric in the upper limbs.  Muscle power was normal on the left side of the body.  On the right side, there was a mild (4+/5) weakness of ankle dorsiflexion and a moderate weakness (4/5) of hip flexion. 

Reflexes:  Deep tendon reflexes were normal and symmetric (2/4) in the upper limbs.  In the lower limbs, the right knee jerk and ankle jerk were slightly brisker than the left.  Plantar reflexes were flexor bilaterally. 

Sensory System:  Sensory examination was normal on the left side.  On the right side, there was an altered appreciation of pinprick throughout most of the right lower limb and posterior trunk region.  There appeared to be an elevated sensory threshold, and, then once the sensation was perceived, there was a disagreeable tingling associated with it.  Joint position sense was impaired in the right foot when compared to the left. 

Cerebellar Function:  Intact.

Gait and Stance:  Regular gait was performed normally, although there was a slight tendency to circumduct the right foot.  Tandem gait was normal, and the Romberg test was negative.


1.  Is there evidence of peripheral nervous system (peripheral nerve, spinal nerve, or dorsal/ventral root) involvement in this case, and, if so, what is the level(s) of that involvement?

2.  Are the patient’s right lower limb motor and reflex examinations suggestive of an upper motor neuron or lower motor neuron process?

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

4.  Could this patient’s signs and symptoms be localized to any other place in the central nervous system?  If so, what is the precise localization of her neurologic lesion, including the side of involvement?  Indicate the specific structure(s) involved by this lesion.  

5.  In general, what type of pathologic process do you think is involved in this case, and what would be included in the differential diagnosis?  

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


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