Brief Summary
Okay ji, so this video is basically a case presentation and discussion of a 50-year-old female patient, Gaitri, with progressive lower limb weakness, sensory loss, and bowel-bladder dysfunction. The discussion covers the diagnostic process, differentiating between upper and lower motor neuron lesions, myelination-related disorders, and compressive lesions. The final diagnosis points towards malignant arachnoiditis with drop metastasis. Key takeaways include:
- Importance of detailed history and clinical examination in neurological diagnosis.
- Differentiating between UMN and LMN lesions.
- Understanding pressure-sensitive tracts and their clinical implications.
- Recognizing the significance of myelination in neurological disorders.
Patient Presentation and Initial Symptoms
So, the presenter starts by introducing Gaitri, a 50-year-old female, Hindu, who studied till 7th standard and works as a tailor. She's right-handed and comes from Hassan. The main complaint is weakness in both lower limbs for two months, loss of sensation below the umbilicus, and bowel and bladder disturbances, all developing over the past month.
History of Presenting Illness
The patient was fine two months ago when she started developing weakness in her lower limbs. It began gradually, with difficulty in getting up and walking. Over two weeks, the weakness progressed, needing assistance to move around. Initially, there were no sensory or bowel-bladder issues. In the next two weeks, she couldn't even move in bed without help and developed numbness, starting from the ankles and moving up the legs, followed by loss of sensation to touch, hot, and cold. She also experienced bowel and bladder issues, like not feeling the fullness of her bladder, leading to abdominal distension and involuntary urination.
Additional History and Handedness
The patient reported occasional back pain but no injury, dog bite, recent vaccination, surgery, or radiation. There were no symptoms of fever, cough, weight loss, or bone pain. She also denied any Lyme disease symptoms, joint pain, photosensitivity, rash, high-risk behavior, fever with chills, cloudy urine, or breathing issues. The presenter confirmed the patient's right-handedness by asking about routine activities like threading needles and combing hair. The relevance of handedness in neurology is discussed, especially in planning surgeries for tumors or epilepsy, as it helps predict language-related outcomes.
Determining Handedness and Motor Pathway Involvement
Various methods to determine handedness are discussed, including observing routine activities, using tools like an illuminoscope, and simple tests like folding hands or putting thumbs down. EEG can also help, as the left hemisphere is more active during language-related tasks, showing less alpha rhythm (relaxation). The discussion then shifts to the patient's difficulty in walking and getting up. It's clarified that the weakness came before the sensory symptoms, indicating a motor pathway issue. The goal is to determine if it's an upper motor neuron (UMN) or lower motor neuron (LMN) problem.
Differentiating UMN and LMN Weakness
LMN issues can involve muscles, neuromuscular junctions, motor roots, or motor nerves. UMN issues involve motor tracks in the spinal cord or brain. The presenter asks if the patient's difficulty in getting up was due to stiffness or floppiness. Stiffness suggests UMN, while floppiness suggests LMN. Heaviness, in this context, indicates weakness, not actual weight. UMN patients might drag their limbs due to stiffness, while LMN patients might have a high-stepping gait. Examination findings for UMN include exaggerated deep reflexes, absent superficial reflexes, and upgoing plantar response, while LMN shows loss of both deep and superficial reflexes and a flexor plantar response.
Special Considerations for Motor Tracts and Sensory Symptoms
Cerebral paraplegia, caused by lesions in the paracentral lobule, is discussed. These patients can have cortical sensory loss, seizures, and disproportionate weakness. Motor and posterior column fibers are the most myelinated. If the symptoms had been present for a long time, tractopathies (diseases involving specific tracts) would be considered. Since the symptoms developed over a month, a myelin-based disorder is suspected. The severity of motor weakness is graded using the Ashworth scale. The discussion moves to sensory symptoms, focusing on whether the patient felt burning, pricking, or cold sensations.
Sensory Involvement and Bladder Dysfunction
The patient only reported numbness, suggesting involvement of proprioceptive fibers, which are highly myelinated, further supporting the possibility of a myelin-related disorder. The sensory loss went up to the umbilicus. LMN issues usually cause length-dependent sensory loss, but since the loss reached the umbilicus, UMN involvement is suspected. The discussion then covers bladder dysfunction, differentiating between automatic and autonomous bladders.
Autonomous vs. Automatic Bladder
Autonomous bladder is a completely disconnected bladder with only the sacral center intact, leading to a large bladder, no sensation of fullness, and continuous dribbling. Automatic bladder has an intact sacral center but disconnected higher centers, leading to a smaller bladder capacity, automatic emptying, and residual urine. The patient's symptoms suggest an autonomous bladder. Shock bladder, which occurs after sudden spinal cord transaction, is also discussed.
Spinal Cord Syndromes and Differential Diagnosis
The patient's condition is classified as a subacute pancord syndrome, involving motor, sensory, and autonomic systems. The initial motor involvement and later proprioceptive issues suggest a myelin-related problem. Pressure sensitivity, ischemia sensitivity, and toxic sensitivity are discussed. Pressure-sensitive tracts are the posterior column and corticospinal tract, suggesting a compressive lesion. The subacute nature of the condition also points towards compression.
Differentiating Compressive and Non-Compressive Lesions
Compressive lesions can be extradural, intradural, or intramedullary. Extradural compressions, like disc issues, can cause gibbus, tenderness, and root pains. Intradural compressions, like nerve root tumors, are usually eccentric and cause root pains. Intramedullary lesions, like syringomyelia, cause descending suspended dissociated anesthesia. Acute non-compressive lesions present as pancord syndromes, while chronic ones have vague upper levels and distant signs. Despite considering compression, the presenter still leans towards demyelination due to the symmetrical and pancord nature of the symptoms.
Final History and Physical Examination
The patient has a history of a lump in her left breast with blood and serious discharge from the nipples which was operated 11 years back then she had similar history of lump in the left breast which was operated 8 month back. General physical examination reveals a middle-aged woman with a urinary catheter and left supraclavicular lymphadenopathy. Neurological examination shows increased tone (spasticity) in the lower limbs, 0/5 power in all lower limb muscles, trunkal muscle weakness, absent abdominal and anal reflexes, and bilateral extensor plantar responses. Sensory loss is present below the umbilicus.
Diagnosis and Anatomical Localization
The final diagnosis is a pancord syndrome with LMN involvement, likely malignant arachnoiditis with drop metastasis. This involves the sacral roots and a lesion at the D10 level. Compression is also considered due to the involvement of motor tracts. The presenter suggests milo radical involvement, likely arachnoiditis or drop metastasis. The anatomical localization includes a motor level at D10, sensory level at D10, and LMN involvement of the sacral roots.
Radiological Findings and Clinical Significance
The MRI shows compression fracture and subluxation at the D9-D10 level, multiple light regions in many vertebras. The cervical spine is normal. The white vertebra are called ivory vertebras. The spinal cord as such intrinsic leation is not there that rules out demilation also. The presenter emphasizes the importance of clinical neurology and understanding pressure-sensitive tracts.
Importance of Clinical Neurology and Truthfulness
The presenter stresses the importance of clinical skills over relying solely on investigations, which can lead to misdiagnosis and unnecessary expenses. She shares her experience of being truthful to patients, even when unsure, and gaining their trust over time. She encourages young doctors to be committed and truthful, as they hold the patient's life in their hands.
Paraneoplastic Conditions and Anatomical Localization
Paraneoplastic conditions are unlikely due to the definite level of involvement. The anatomical localization is further refined: motor level at D10, sensory level at D10, reflex level at D6 (due to absent upper abdominal reflex), and LMN involvement of the sacral roots. The presenter concludes by reminding the audience of the formula to approximate the vertebra versus card level.
