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bonmar -> clonus (November 8, 2006 2:00:00 PM)
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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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