The number of needle pricks in the EMG test was limited, as the patient was afraid of needles, but electromyography from the right extremities revealed chronic peripheral neurogenic changes in the abductor digiti minimi muscle and extensor group, while in the first dorsal interosseous, subacute peripheral neurogenic changes were seen with signs of mild denervation. Neurographic examination, including F-responses in the lower extremities, was normal. F-responses were delayed in both ulnar nerves, approximately 30 – 35 ms (normally < 28 ms), difficult to detect for the right median nerve and in the upper range of normal for the left median nerve. MRI of the spinal cord showed marked atrophy from C4 to Th2 and two longitudinal symmetrical T2-weighted hyperintense lesions from C2 to Th2 ( 4 – 5 mV, but atrophy will affect the amplitude). Cerebrospinal fluid examination yielded normal results. Ganglioside (GM1) antibodies were negative. A clinical neurophysiological examination with MR neurography of both upper extremities and the lower right extremity, as well as electromyography (EMG) from both right extremities, was also carried out.īlood tests, including creatine kinase (CK), which was checked several times, were completely normal. The clinical picture was fairly unusual – with findings suggestive of an isolated lower motor neuron involvement delimited to medullary level C6 to Th1.Īn extensive work-up was performed with blood tests, MRI of the head and medulla, and cerebrospinal fluid examination. The possibility of an atypical form of plexus neuritis was also considered, although we regarded this as less likely because there was no pain. Other possible diagnoses we initially took into consideration were benign forms of motor neuron disease, structural lesions of the cervical spine, a form of motoric neuropathy and neurogenic thoracic outlet syndrome. However, it would be unusual for only the small hand muscles to be affected. The relatively slow symptom progression meant that a neurodegenerative disease, such as spinal muscular atrophy, was an obvious possible diagnosis. Cranial nerve examination and mental status were unremarkable.
SLENDER HANDS FREE
She had no neck pain, free movement of the cervical spine and was negative for Lhermitte’s sign. Reflexes were of average liveliness and symmetry, and plantar reflexes were flexor. The patient reported normal sensation for all types of sensory stimuli. No fasciculations were observed and tests of coordination were unremarkable. Fine finger movements were reduced in speed, reflecting the paresis, but otherwise normal.
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