LESIONS

A Guide to Localisation in Neurology

Case 13 - numb hands and stiff legs

Case

A 78 year old woman presented with several weeks of problems with hand actions and walking difficulties.

3 months before she had been in good health, keeping fit and active. She then noted her legs being ‘not quite right’ and felt she was limping on the right leg, but had no pain. Her toes felt a little numb if she leaned on them.

As the days passed she noted her fingers feeling slightly numb and it was more difficult to do fine tasks such as fastening jewellery or opening packets and she was dropping items at times. This had become more pronounced over time making it difficult to perform certain daily tasks. Her hands felt somewhat weak and as if they simply would not work normally.

Her walking had deteriorated, becoming slower and with both legs feeling stiff and slightly weak, and she was walking increasingly short distances, though without requiring any assistance such as a stick.

She did not have any cranial nerve symptoms (e.g. changes to speech, swallowing, vision, hearing), neck or back pain, electric shock sensations on neck movement, or changes to bladder or bowel function. She felt systemically well. There had been no injuries, neck manipulation, or recent operations.

Her past medical history was unremarkable. She took no medications. She lived independently and was normally highly active, but her capacity to exercise had dramatically reduced since the problem began.

On examination she had:

• Mild spasticity in the right arm and leg, and sustained clonus in both ankles
• Normal muscle bulk throughout, including in the forearm, interosseous, thenar and hypothenar eminensces, and no fasciculations
• Bilateral 4/5 weakness in the following - finger extension, flexion and abduction; thumb abduction; right hip and knee flexion (normal left leg). All other groups were full power.
• Globally brisk reflexes including pectoral jerks and crossed adductors, reflex spread in upper limbs (e.g. biceps jerk caused finger flexion), bilateral Hoffman reflexes, and an upgoing right plantar with fanning toes (Babinski response)
• Minor sensory reduction to touch and pinprick in fingertips, palms and dorsal hands; no clear dermatomal pattern but normalised towards wrists . Vibration and joint position sense intact. No sensory abnormality in legs.
• A diplegic gait pattern, with stiff legs and some inward turning of the legs
• Minor sensory reduction to touch and pinprick in fingertips, palms and dorsal hands; no clear dermatomal pattern but normalised towards wrists . Vibration and joint position sense intact. No sensory abnormality in legs.

Cranial nerves were normal as was the rest of the examination.