My legs don’t work, doc

The story

A 28 year old woman presented to the neurology clinic with a 3 month history of progressive problems with her walking.

She was struggling to get up and down the stairs, get out of a low chair and do her normal job.

On closer questioning, he also reported some sensory disturbance in the left foot and a sense of urinary urgency.

Past medical history was of Grave’s disease and she has recently had a relapse. She was awaiting further treatment for this.

Medication was propranolol and carbimazole.

On examination

  • Speech & higher mental function – normal
  • Gait – abnormal; legs clearly weak; unable to rise from standing with the arms crossed
  • Visual assessment – normal
  • Motor cranial nerves – normal
  • Sensory cranial nerves – normal
  • Upper limbs – inspection, tone, power, coordination and sensation all normal; reflexes a little brisk
  • Lower limbs – inspection normal; tone increased with bilateral ankle clonus; power reduced bilaterally (hip flexors weaker than hip extensors); reflexes brisk and spreading; plantars extensor; sensory exam (rarely helpful) showed a reduction in pin and temperature sensation in the left foot.

Questions?

  1. Is this a “central” or “peripheral” problem?
  2. What helps you decide?
  3. Where is the problem most likely to be?
  4. What are the top 3 potential causes?
  5. If you had only one test you could do, what would it be?

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