Cervical Cord Compression and ALS

by

Michael H. Rivner, M.D.

73-year-old woman who was in fairly good health until 3 years ago when she developed low back pain. She had two lumbar laminectomies that produced relief of her pain. Her low back pain was relieved following the second surgery. About 18 months ago, she noticed that she was dragging her left leg. A head MRI showed a right lacunae infarct. She developed increasing weakness of her left leg and then her right leg. More recently she developed upper extremity problems. She had been walking with a cane but now needs a walker. She has been falling a lot. She has vague sensory complaints. She also is having problems with bladder and bowel incontinence and wears Attends. She also complains of syncopal spells and feeling faint and dizzy when she stands up. She denies dysphagia and dysarthria.

Exam: Mental status, speech and language functions are normal. CN: normal except for tongue fasciculations. Motor: Wasting of bilateral FDI and left thenar eminence. She had wasting of her left thigh. LUE was 4/5. RUE was 4+/5. LLE- hip 4/5, knee 4-/5, ankle dorsiflexion 1/5, and plantar flexion 2/5. She has no movements of her toes. RLE-distally 4-/5, proximally 4+/5. Her gait was unsteady and slow. She had a left foot drop. He had fasciculations of her shoulders and tongue. Sensory exam was normal to fine touch but vibratory was diminished in both lower extremities. Her reflexes were 2+ except her ankle jerks which were absent. She has a left Babinski's sign. She has a bilateral Hoffman’s and palmar-mental signs. She is not orthostatic. She does not have spasticity.

Nerve conductions:

Motor

Nerve

Amp-prox

Amp–dist

CV

DL

F-wave

L Peroneal Motor

NR

NR

NR

NR

 

L Ulnar Motor

1.1

1.3

37.5

3.6

 

L Ulnar Motor (BE)

1.2

1.3

46.8

3.6

 

R Ulnar Motor

7.3

8.0

49.3

2.8

30.6

R Tibial Motor

0.3

0.5

40.2

5.7

NR

 

Sensory

Nerve

Amp

DL

CV

Distance

Left Sural

2.4

4.6

38.2

14.5

Left Ulnar Palmar Sen

6.5

2.3

 

8.0

Right Ulnar Palmar Sen

14.1

2.0

 

8.0

Right Sural

3.8

36

59.1

14.0

Needle Exam:

Muscle

Insert Act

Fib

Fasc

VMUP

R FDI

increased

Positive Waves

3+

1+

Decreased recruitment

Increased firing freq

Increased Size

R Deltoid

Increased

Positive Waves

1+

0

Increased Size

Decreased Recruitment

Increased Firing Freq

R Vastus Lateralis

Increased

Positive Waves

2+

0

Increased Size

Markedly decreased Recru

Increased Firing Freq

R Med Gastroc

Increased

Positive Waves

3+

0

Decreased Recruitment

Increased Firing Freq

L EIP

Increased

Positive Waves

1+

0

Decreased Recruitment

L Biceps Brachii

Increased

CRDs

Positive Waves

3+

0

Decreased Recruitment

L Tib Ant

Increased

Positive Waves

3+

0

No Units

L Iliopsoas

Increased

Positive Waves

2+

0

Increased Size

L Tongue

Increased

Positive Waves

1+

0

Normal

L Anal Sphincter

Increased

1+

0

Decreased Recruitment

R Thoracic Paraspinals

Poor Relaxation

0

0

Normal

L Thoracic Paraspinals

Increased

Positive Waves

CRDs

1+

0

Decreased Recruitment

R Biceps Brachii

Increased

Positive Waves

1+

1+

Normal

R Thoracic Paraspinals

Increased

Positive Waves

2+

0

Decreased Recruitment

R Orb Oculi

Increased

+/-

0

Normal

R Mentalis

Normal

0

0

Normal

Imaging Studies:

MRI of Head: Showed a small lacunae infarction in the right posterior thalamus probably not the cause of the patient’s left leg weakness. Cortical Atrophy was also seen.

MRI of L/S spine: Multilevel lumbar degenerative disease. Arachnoiditis at L3-4 and L4-5 and neural foraminal stenosis. Sacral region not well visualized on films.

MRI of Cervical Spine:

Lumbar Puncture:

CSF protein 59

CSF Glucose 56

13 RBCs

1 WBCs

Questions: I am bothered by several things:

1) The incontinence.

2) The Cervical MRI Should it be operated on even though I believe that this cannot explain all this patients symptoms. She has L/S disease but her lower extremities are behaving more like ALS then spine disease.

3) Does anyone think this is not ALS?

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Modified March 31, 2003

(c) M.H. Rivner