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clonus
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clonus - November 8, 2006 2:00:00 PM
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bonmar
Posts: 137
Joined: August 15, 2000
From: Boston, MA
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I evaluated a new patient yesterday with the diagnosis of "small left lumbar disc herniation."
HPI - Pt is a 33 yo healthy male. Approx 6-7 months ago, insidious onset of numbness/tingling in his legs as well as tingling in his arms whenever he looked up (mainly when playing catch and looking up to catch the ball). This had been going on for quite some time (approx 6 months)prior to seeking medical attention. What finally brought him to the MD was balance disturbances. Initial thought was MS but pt states tests were negative. A subsequent MRI revealed a large cervical disc herniation as well as a small lumbar herniation. The patient underwent an anterior cervical fusion C4/5 (pt believes) using a titanium plate. He was not braced following surgery. In fact, he had no restrictions. He RTW and the gym 5 weeks p-op and began light workouts of lifting and walking on the treadmill. He states he had some residual N/T in his LE's but mild.
3 weeks ago or approx 10 weeks p-op, the patient began running on trails. He ran approx 2 miles, 3x/week for 2 weeks and developed significant LE/buttock numbness. He called his surgeon who told him just to see his primary MD (???)....primary MD now refers this patient for PT for lumbar disc.
The patient has not worked out in the past week and states he feels great...even better than before running. No pain, no numbness/tingling. Denies dizziness, HA's, bowel/bladder changes, visual disturbances, and balance disturbances.
Objective findings reveal painfree and WNL ROM of the trunk. CROM into rotation/sidebending are also WNL/painfree. LE strength reveals mild left LE weakness in the L4/5 distribution. With repeated testing of strength of the LLE, weakness progresses to 3+ (from 4+). Reflexes of the knee were brisk bilat and hyperreflexia of the ankles. In fact, a slight clonus was reproduced with reflex testing of the ankles. A quick stretch of each ankle reveals unsustained clonus, R, and sustained clonus L. The patient states the MD (surgeon) is aware of the clonus...he had it after surgery. The patient continues on to tell me that in the morning his hands also "shake". I could not reproduce clonus in his wrists. Negative babinski.
Finally....my question...is it possible to have clonus in the absence of UMN dysfunction? What do you think is going on here?
Thanx
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Re: clonus - November 8, 2006 3:13:00 PM
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KAK
Posts: 200
Joined: December 1, 2004
Status: offline
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I wonder if the clonus was there pre-surgery and is residual from chord compression from the cervical disc.
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Re: clonus - November 8, 2006 5:31:00 PM
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touchiba
Posts: 101
Joined: November 11, 2002
From: PA
Status: offline
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There could be some residual cord damage from the surgery if the spinal cord was moved for any reason It could have been tractioned too much or for too long. I was speaking to a surgeon recently and he told me about a case where a collegue of his held the cord out of the way for too long under traction and the patient had severe post op complications because of it.
I dont understand surgeons. They're in, they're out, and they want to have nothing to do with the patient. They deny that any post op symptoms can be due to the surgery. It's hard to deny when the onset is the day of or day after the surgery. At least they could do is acknowledge the possibility.
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Re: clonus - November 9, 2006 12:57:00 AM
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bonmar
Posts: 137
Joined: August 15, 2000
From: Boston, MA
Status: offline
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Thank you both for the replies. I do get the feeling the surgeon has basically finished up with this patient. I don't understand why he did not want to see him when he called complaining of BLE sensory changes.
Will time help the clonus or is this permanent damage?
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Re: clonus - November 10, 2006 12:25:00 PM
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KAK
Posts: 200
Joined: December 1, 2004
Status: offline
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If there is swelling about the chord, his symptoms could improve with time as the swelling resolves. My guess is that he may always have a touch of neuro signs-time will tell (months of time). This is a tough one as there obviously may be cervical as well as lumbar components to his symptoms and it’s hard to shake it all out.
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