offthegrid
New member
- Joined
- Jan 16, 2023
- Messages
- 2
- Reason
- Learn about ALS
- Diagnosis
- 00/0000
- Country
- US
In March 2022 I began to experience foot drop on the left side. I went to my GP in August who noticed that there was weakness also in my right foot. At this time, it is difficult to walk and hold my balance while standing. I am also experiencing muscle twitching in my back and legs. I have included the notes from my recent Neurodiagnostic Lab appointment and an attachment that shows results. I have also included the MRI results. At first the doctor thought I it was severe spinal stenosis but the MRI doesn't show that my back is bad enough to match the findings on the EMG. He has included an Addendum and has referred me to a neurologist. Could this be ALS?
Impression:
1. Abnormal study
2. There is electrodiagnostic evidence of acute on chronic, severe, neuropathic process. There is active denervation.
3. There is no electrodiagnostic evidence suggestive of peripheral polyneuropathy, lumbar plexopathy or myopathy.
Discussion:
Findings consistent with a severe, chronic neuropathic process with axonal features and motor involvement. There is evidence of active denervation, worst distally. Would be most suspicious of severe lumbar stenosis, possibly in the setting of anterolisthesis at L4-L5. Does not appear to be evidence of sensory component, reducing suspicion for combined sensorimotor process. She does have evidence of brisk reflexes and ankle clonus. Strongly agree with lumbar MRI. Would recommend neurosurgical consultation, if evidence of stenosis. If MRI unrevealing, would recommend formal neurology consultation as soon as possible.
ADDENDUM:
Lumbar MRI reviewed and evidence of severe left L5-S1 neuroforaminal stenosis and right L4-L5 neuroforaminal stenosis and lateral recess stenosis. Findings could account for a portion of her symptoms, however appear to be more widespread myotomal involvement. There is also does not appear to be evidence of central stenosis that would account for potential upper motor neuron changes. Would recommend formal neurology consult.
MUSCULOSKELETAL:
MOTOR STRENGTH: 4/5 Bilateral DF, EHL. 5-/5 KE, KF.
Muscle bulk: Normal
NEUROLOGICAL:
Deep tendon reflexes: 3/4 bilateral lower extremity. 1-2/4 B/L UE
Sensation:
Lower limbs: Intact roughly in the all dermatomes and peripheral nerve distributions bilaterally
Ankle clonus: 2-3 beats B/L
Hoffman's: Negative bilaterally.
HISTORY:
Patient is a 49 year-old female who presents with chronic lower back and bilateral leg symptoms. Symptoms started insidiously in March of this year. She has radiating pain from her back to her legs. She has had progressive weakness especially dorsiflexion. Her gait has deteriorated. No changes in bowel bladder function. No issues with upper extremities. No history of diabetes. No family history of neurological conditions.
NCV FINDINGS: Evaluation of the Left peroneal motor nerve showed no response (Ankle), no response (B Fib), and no response (Poplt). The Right peroneal motor nerve showed reduced amplitude (Ankle, 1.4 mV), reduced amplitude (B Fib, 1.4 mV), and reduced amplitude (Poplt, 1.3 mV). The Left tibial motor and the Right tibial motor nerves showed prolonged distal onset latency (L6.3, R13.8 ms) and reduced amplitude (L4.7, R0.0 mV). All remaining nerves (as indicated in the following tables) were within normal limits.
Needle evaluation of the Right anterior tibialis muscle showed increased insertional activity, increased spontaneous activity, increased motor unit amplitude, increased motor unit duration, slightly increased polyphasic potentials, and diminished recruitment. The Right Fibularis Long and the Left Fibularis Long muscles showed increased insertional activity, slightly increased spontaneous activity, increased motor unit amplitude, increased motor unit duration, and diminished recruitment. The Right gastroc and the Left anterior tibialis muscles showed increased insertional activity, moderately increased spontaneous activity, increased motor unit amplitude, increased motor unit duration, and diminished recruitment. The Right vastus medialis and the Left vastus medialis muscles showed increased insertional activity, increased motor unit amplitude, increased motor unit duration, moderately increased polyphasic potentials, and diminished recruitment. The Right gluteus maximus and the Left gluteus maximus muscles showed increased motor unit amplitude, increased motor unit duration, and diminished recruitment. The Left posterior tibialis and the Left tensor fascia lata muscles showed increased insertional activity, moderately increased spontaneous activity, increased motor unit amplitude, increased motor unit duration, slightly increased polyphasic potentials, and diminished recruitment. The Left gastroc muscle showed increased insertional activity, slightly increased spontaneous activity, increased motor unit amplitude, and diminished recruitment. All remaining muscles (as indicated in the following table) showed no evidence of electrical instability.
MRI LUMBAR SPINE W/O CONTRAST - Details
Details
Study Result
Impression
1. No acute abnormality.
2. At L5-S1, there is impingement on the exiting portion of the left L5 nerve root, secondary to disc and facet disease.
3. At L3-4, there may be impingement on the traversing portion of the right L4 nerve root secondary to a disc bulge.
4. Additional sites of disc and facet disease with encroachment on the spinal canal and neural foramina, detailed above. No other sites of suspected nerve root impingement.
Exam images have been permanently archived.
Narrative
PROCEDURE: MRI LUMBAR SPINE WO IV CONTRAST
COMPARISON STUDY: None
REASON FOR STUDY: Lumbar radiculopathy, symptoms persist with > 6 wks treatment
TECHNIQUE: The last full disk is arbitrarily called L5-S1. Please see saved images.
MRI of the lumbar spine was performed without IV contrast
The following sequences were obtained:
PROTOCOLS:
Axial T1.
Axial T2.
Sagittal T1.
Sagittal T2.
Sagittal STIR
FINDINGS:
There is moderate levoscoliosis. There is grade 1 anterolisthesis at L4-5. No other significant subluxations. There is disc desiccation from L3-4 through L5-S1, with severe disc space narrowing at L4-5 and L5-S1, and moderate narrowing at L3-4. No fracture identified. The spinal cord terminates at the T12-L1 level, and the distal cord is unremarkable.
T12-L1: No significant compromise of the canal or foramina.
L1-L2: Hypertrophic changes in the facets. No significant compromise of the canal or foramina.
L2-L3: Hypertrophic changes in the facets. No significant compromise of the canal or foramina.
L3-L4: Hypertrophic changes in the facets. Mild broad-based posterior disc bulge/osteophyte, most pronounced posterolaterally to the right. The bulging tissue abuts the traversing portion of the right L4 nerve root, with mild effacement of the perineural fat planes. Moderate encroachment on the right neural foramen and mild encroachment on the left, without definite impingement on the exiting nerve roots.
L4-L5: Severe hypertrophic and degenerative changes in the facets, grade 1 anterolisthesis and a mild broad-based posterior disc bulge results in mild AP narrowing of the spinal canal. No definite impingement on the traversing nerve roots. Moderate to severe encroachment on the right neural foramen and moderate encroachment on the left, without impingement on the exiting nerve roots.
L5-S1: Moderate to severe hypertrophic and degenerative changes in the facets, more pronounced on the left. Mild broad-based posterior disc bulge/osteophyte, more pronounced posterolaterally to the left. Minimal AP narrowing of the spinal canal. Severe encroachment on the left neural foramen, with moderate to severe effacement of the perineural fat planes associated with the exiting portion of the left L5 nerve root. Minor encroachment on the right neural foramen.
Impression:
1. Abnormal study
2. There is electrodiagnostic evidence of acute on chronic, severe, neuropathic process. There is active denervation.
3. There is no electrodiagnostic evidence suggestive of peripheral polyneuropathy, lumbar plexopathy or myopathy.
Discussion:
Findings consistent with a severe, chronic neuropathic process with axonal features and motor involvement. There is evidence of active denervation, worst distally. Would be most suspicious of severe lumbar stenosis, possibly in the setting of anterolisthesis at L4-L5. Does not appear to be evidence of sensory component, reducing suspicion for combined sensorimotor process. She does have evidence of brisk reflexes and ankle clonus. Strongly agree with lumbar MRI. Would recommend neurosurgical consultation, if evidence of stenosis. If MRI unrevealing, would recommend formal neurology consultation as soon as possible.
ADDENDUM:
Lumbar MRI reviewed and evidence of severe left L5-S1 neuroforaminal stenosis and right L4-L5 neuroforaminal stenosis and lateral recess stenosis. Findings could account for a portion of her symptoms, however appear to be more widespread myotomal involvement. There is also does not appear to be evidence of central stenosis that would account for potential upper motor neuron changes. Would recommend formal neurology consult.
MUSCULOSKELETAL:
MOTOR STRENGTH: 4/5 Bilateral DF, EHL. 5-/5 KE, KF.
Muscle bulk: Normal
NEUROLOGICAL:
Deep tendon reflexes: 3/4 bilateral lower extremity. 1-2/4 B/L UE
Sensation:
Lower limbs: Intact roughly in the all dermatomes and peripheral nerve distributions bilaterally
Ankle clonus: 2-3 beats B/L
Hoffman's: Negative bilaterally.
HISTORY:
Patient is a 49 year-old female who presents with chronic lower back and bilateral leg symptoms. Symptoms started insidiously in March of this year. She has radiating pain from her back to her legs. She has had progressive weakness especially dorsiflexion. Her gait has deteriorated. No changes in bowel bladder function. No issues with upper extremities. No history of diabetes. No family history of neurological conditions.
NCV FINDINGS: Evaluation of the Left peroneal motor nerve showed no response (Ankle), no response (B Fib), and no response (Poplt). The Right peroneal motor nerve showed reduced amplitude (Ankle, 1.4 mV), reduced amplitude (B Fib, 1.4 mV), and reduced amplitude (Poplt, 1.3 mV). The Left tibial motor and the Right tibial motor nerves showed prolonged distal onset latency (L6.3, R13.8 ms) and reduced amplitude (L4.7, R0.0 mV). All remaining nerves (as indicated in the following tables) were within normal limits.
Needle evaluation of the Right anterior tibialis muscle showed increased insertional activity, increased spontaneous activity, increased motor unit amplitude, increased motor unit duration, slightly increased polyphasic potentials, and diminished recruitment. The Right Fibularis Long and the Left Fibularis Long muscles showed increased insertional activity, slightly increased spontaneous activity, increased motor unit amplitude, increased motor unit duration, and diminished recruitment. The Right gastroc and the Left anterior tibialis muscles showed increased insertional activity, moderately increased spontaneous activity, increased motor unit amplitude, increased motor unit duration, and diminished recruitment. The Right vastus medialis and the Left vastus medialis muscles showed increased insertional activity, increased motor unit amplitude, increased motor unit duration, moderately increased polyphasic potentials, and diminished recruitment. The Right gluteus maximus and the Left gluteus maximus muscles showed increased motor unit amplitude, increased motor unit duration, and diminished recruitment. The Left posterior tibialis and the Left tensor fascia lata muscles showed increased insertional activity, moderately increased spontaneous activity, increased motor unit amplitude, increased motor unit duration, slightly increased polyphasic potentials, and diminished recruitment. The Left gastroc muscle showed increased insertional activity, slightly increased spontaneous activity, increased motor unit amplitude, and diminished recruitment. All remaining muscles (as indicated in the following table) showed no evidence of electrical instability.
MRI LUMBAR SPINE W/O CONTRAST - Details
Details
Study Result
Impression
1. No acute abnormality.
2. At L5-S1, there is impingement on the exiting portion of the left L5 nerve root, secondary to disc and facet disease.
3. At L3-4, there may be impingement on the traversing portion of the right L4 nerve root secondary to a disc bulge.
4. Additional sites of disc and facet disease with encroachment on the spinal canal and neural foramina, detailed above. No other sites of suspected nerve root impingement.
Exam images have been permanently archived.
Narrative
PROCEDURE: MRI LUMBAR SPINE WO IV CONTRAST
COMPARISON STUDY: None
REASON FOR STUDY: Lumbar radiculopathy, symptoms persist with > 6 wks treatment
TECHNIQUE: The last full disk is arbitrarily called L5-S1. Please see saved images.
MRI of the lumbar spine was performed without IV contrast
The following sequences were obtained:
PROTOCOLS:
Axial T1.
Axial T2.
Sagittal T1.
Sagittal T2.
Sagittal STIR
FINDINGS:
There is moderate levoscoliosis. There is grade 1 anterolisthesis at L4-5. No other significant subluxations. There is disc desiccation from L3-4 through L5-S1, with severe disc space narrowing at L4-5 and L5-S1, and moderate narrowing at L3-4. No fracture identified. The spinal cord terminates at the T12-L1 level, and the distal cord is unremarkable.
T12-L1: No significant compromise of the canal or foramina.
L1-L2: Hypertrophic changes in the facets. No significant compromise of the canal or foramina.
L2-L3: Hypertrophic changes in the facets. No significant compromise of the canal or foramina.
L3-L4: Hypertrophic changes in the facets. Mild broad-based posterior disc bulge/osteophyte, most pronounced posterolaterally to the right. The bulging tissue abuts the traversing portion of the right L4 nerve root, with mild effacement of the perineural fat planes. Moderate encroachment on the right neural foramen and mild encroachment on the left, without definite impingement on the exiting nerve roots.
L4-L5: Severe hypertrophic and degenerative changes in the facets, grade 1 anterolisthesis and a mild broad-based posterior disc bulge results in mild AP narrowing of the spinal canal. No definite impingement on the traversing nerve roots. Moderate to severe encroachment on the right neural foramen and moderate encroachment on the left, without impingement on the exiting nerve roots.
L5-S1: Moderate to severe hypertrophic and degenerative changes in the facets, more pronounced on the left. Mild broad-based posterior disc bulge/osteophyte, more pronounced posterolaterally to the left. Minimal AP narrowing of the spinal canal. Severe encroachment on the left neural foramen, with moderate to severe effacement of the perineural fat planes associated with the exiting portion of the left L5 nerve root. Minor encroachment on the right neural foramen.
