‘Jack has leg weakness’

Published on 10/04/2015 by admin

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Last modified 10/04/2015

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Problem 41 ‘Jack has leg weakness’

Jack is a 39-year-old electrical engineer. In the past few months, he has noticed that his left leg feels weak. There is intermittent numbness. His wife tells you that Jack has been ‘walking funny’.

Q.1

What other questions would you like to ask Jack to clarify the history further?

On specific enquiry, Jack says that he has experienced some headaches recently. These are not associated with nausea and vomiting. He has no spinal pain or sciatica. He has no significant family history. His general health has been excellent.

Q.2

What relevance has his headache in the context of his leg weakness?

You examine him carefully. He is a well-looking man who appears slightly anxious. His temperature is 37.1°C. His blood pressure is 140/80 mmHg and heart rate 85 bpm. Chest and abdominal examination findings were unremarkable.

Neurological examination shows an abnormal gait with an obvious limp. There were no cranial nerve deficits. Upper limb examination shows no focal deficits. Lower limb examination shows a pyramidal pattern of weakness which is most prominent distally (NHMRC power graded 3/5) and increased tone in the left lower limb. Left lower limb reflexes were hyper-reflexic (right lower limb reflexes normal). There was sustained myoclonus present at the left ankle. Sensory testing to light touch and pin-prick were within normal limits. Distal proprioception was normal bilaterally. Plantar response was equivocal on left and flexor on the right.

Q.3

What do the examination findings indicate?

You put your examination findings together, and think about what to do next.

Q.4

What investigations should you consider?

You perform your investigation of choice.

Q.5

What do the following images show?

You admit Jack to hospital in the neurosurgery unit, and commence him on oral dexamethasone. This resulted in mild improvement of his lower limb weakness. He undergoes a right craniotomy and excision of the intracranial lesion. The surgery was uncomplicated. Postoperatively, Jack’s lower limb weakness was significantly improved over the previous week, and he attends rehabilitation classes with good recovery of function. The histopathology was consistent with meningioma.

Answers

A.1 The clinical history is of utmost importance in the assessment of a neurological illness. In a patient presenting with unilateral limb weakness and sensory disturbance, questions should be directed at gaining clues to aid in neuroanatomical localization. Jack has left leg weakness and numbness, which may potentially be attributed to a lesion(s) in the: 1) right cerebral hemisphere; 2) brainstem; 3) spinal cord; 4) left lumbosacral nerve roots and plexus; 5) peripheral nerves of the left lower limb.

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