Sign-in to Ask A Doctor - 24x7
OR
Sign in with Google
Hello, I Ve Had A Problem For The Last 6-8
Question: Hello,
I've had a problem for the last 6-8 years or so which I've yet to get addressed. In 2013 I developed severe back pain from the top to the bottom of the spine. Spasms in back muscles only, and fasciculations, parasthesias and pain in both arms and both legs as well as pectorals and latissimus dorsi. Fasciculations also in sternocleidomastoid muscles, chin, eye and trapezius (i.e. cranial nerves). Parasthesias but not actual complete numbness. Also some parasthesias at the time in the genital region. Sensation was preserved everywhere to light touch and pinprick, except that light touch causes pain in the hands. My operative assumption at the time was that this was a back problem. Brain MRI showed nothing of note. Full spine MRI done in 2015 showed mild degenerative changes which were age-appropriate, but no compression which would explain these problems, and no myopathy. No significant central stenosis, only mild foraminal stenosis in a few sites, and no listhesis on dynamic flexion or extension views. A neurologist and two back specialists confirmed that in their opinion this could not be cause by the back. I became almost bed bound for about 4 months, wheelchair bound for a year, and have never regained my strength since then. GBS was suggested at the time, but no spinal tap was done. NCS/EMG in 2015 showed essentially normal NCS with some minor low motor response on the right peroneal nerve, but everything else normal. Needle EMG on the other hand showed multilevel chronic radiculopathy at virtually every site tested, cervical levels and left L4-L5 (only the left side of my body was tested). Left First Digital Interosseous showed decreased motor units. My hands and forearms are weak and a mildly atrophied, the left worse than the right, and heelwalking on my left foot causes a mild foot drop. These areas are consistent with the findings on the EMG. I did have one doctor suggest thoracic outlet syndrome as I have diminished pulses and numbness when raising the arms above the head, as well as elongated transverse processes on my C7 vertebra. But this does not account for the overall weakness, failure to recover fully after 5 years, or the fasciculations, weakness and parasthesias in other parts of the body. Things seem to have a waxing and waning pattern, getting somewhat better for several months, and then getting worse. Reflexes in arms are diminished, reflexes in knees are absent. With the exception of my spine muscles, the muscles in the rest of my body are not spastic, but are instead kind of flaccid, especially in my arms. I do have esophageal spams which cause difficultly swallowing sometimes, but at other times not. So technically I have difficulty swallowing, but since it is not constant I think this is a red herring. My tongue is normal size and does not seem to be atrophied. I have not been able to detect any abnormal movements in my tongue when looking at it in the mirror. My ability to stand is limited to about two twenty minute time periods during the day with many shorter walks to kitchen or bathroom. Total out of bed time is about 3-4 hours per day. Morning activity makes me profoundly fatigued and takes hours to recover from. Recently have had tremors in hands when fatigued, only while trying to use them, never when resting. Workups for Lupus and Rhuematoid arthitis were negative. Total cholesterol is 140, LDH =90 and HDL = 30. These seems to be genetically low, since I have never taken any meds to get them like this. Testosterone is low. Problems: Morbid Obesity 330lbs, hypertension, Mild LVH (1mm), SVT, Gerd, prediabetes, Factor V Leiden. Meds=carvedilol, amlodipine, benadryl, ranitidine, pantoprazole, valerian, lorazepam approx 1-2 times per week, vitamin d, fish oil, vitamin b12 (blood levels are normal). QUESTION: what is the differential diagnosis for the weakness, fasciculations, parasthesias and EMG changes? I need some avenues to pursue, since I've not gotten any real answers from my existing medical team.
I've had a problem for the last 6-8 years or so which I've yet to get addressed. In 2013 I developed severe back pain from the top to the bottom of the spine. Spasms in back muscles only, and fasciculations, parasthesias and pain in both arms and both legs as well as pectorals and latissimus dorsi. Fasciculations also in sternocleidomastoid muscles, chin, eye and trapezius (i.e. cranial nerves). Parasthesias but not actual complete numbness. Also some parasthesias at the time in the genital region. Sensation was preserved everywhere to light touch and pinprick, except that light touch causes pain in the hands. My operative assumption at the time was that this was a back problem. Brain MRI showed nothing of note. Full spine MRI done in 2015 showed mild degenerative changes which were age-appropriate, but no compression which would explain these problems, and no myopathy. No significant central stenosis, only mild foraminal stenosis in a few sites, and no listhesis on dynamic flexion or extension views. A neurologist and two back specialists confirmed that in their opinion this could not be cause by the back. I became almost bed bound for about 4 months, wheelchair bound for a year, and have never regained my strength since then. GBS was suggested at the time, but no spinal tap was done. NCS/EMG in 2015 showed essentially normal NCS with some minor low motor response on the right peroneal nerve, but everything else normal. Needle EMG on the other hand showed multilevel chronic radiculopathy at virtually every site tested, cervical levels and left L4-L5 (only the left side of my body was tested). Left First Digital Interosseous showed decreased motor units. My hands and forearms are weak and a mildly atrophied, the left worse than the right, and heelwalking on my left foot causes a mild foot drop. These areas are consistent with the findings on the EMG. I did have one doctor suggest thoracic outlet syndrome as I have diminished pulses and numbness when raising the arms above the head, as well as elongated transverse processes on my C7 vertebra. But this does not account for the overall weakness, failure to recover fully after 5 years, or the fasciculations, weakness and parasthesias in other parts of the body. Things seem to have a waxing and waning pattern, getting somewhat better for several months, and then getting worse. Reflexes in arms are diminished, reflexes in knees are absent. With the exception of my spine muscles, the muscles in the rest of my body are not spastic, but are instead kind of flaccid, especially in my arms. I do have esophageal spams which cause difficultly swallowing sometimes, but at other times not. So technically I have difficulty swallowing, but since it is not constant I think this is a red herring. My tongue is normal size and does not seem to be atrophied. I have not been able to detect any abnormal movements in my tongue when looking at it in the mirror. My ability to stand is limited to about two twenty minute time periods during the day with many shorter walks to kitchen or bathroom. Total out of bed time is about 3-4 hours per day. Morning activity makes me profoundly fatigued and takes hours to recover from. Recently have had tremors in hands when fatigued, only while trying to use them, never when resting. Workups for Lupus and Rhuematoid arthitis were negative. Total cholesterol is 140, LDH =90 and HDL = 30. These seems to be genetically low, since I have never taken any meds to get them like this. Testosterone is low. Problems: Morbid Obesity 330lbs, hypertension, Mild LVH (1mm), SVT, Gerd, prediabetes, Factor V Leiden. Meds=carvedilol, amlodipine, benadryl, ranitidine, pantoprazole, valerian, lorazepam approx 1-2 times per week, vitamin d, fish oil, vitamin b12 (blood levels are normal). QUESTION: what is the differential diagnosis for the weakness, fasciculations, parasthesias and EMG changes? I need some avenues to pursue, since I've not gotten any real answers from my existing medical team.
Hello,
I've had a problem for the last 6-8 years or so which I've yet to get addressed. In 2013 I developed severe back pain from the top to the bottom of the spine. Spasms in back muscles only, and fasciculations, parasthesias and pain in both arms and both legs as well as pectorals and latissimus dorsi. Fasciculations also in sternocleidomastoid muscles, chin, eye and trapezius (i.e. cranial nerves). Parasthesias but not actual complete numbness. Also some parasthesias at the time in the genital region. Sensation was preserved everywhere to light touch and pinprick, except that light touch causes pain in the hands. My operative assumption at the time was that this was a back problem. Brain MRI showed nothing of note. Full spine MRI done in 2015 showed mild degenerative changes which were age-appropriate, but no compression which would explain these problems, and no myopathy. No significant central stenosis, only mild foraminal stenosis in a few sites, and no listhesis on dynamic flexion or extension views. A neurologist and two back specialists confirmed that in their opinion this could not be cause by the back. I became almost bed bound for about 4 months, wheelchair bound for a year, and have never regained my strength since then. GBS was suggested at the time, but no spinal tap was done. NCS/EMG in 2015 showed essentially normal NCS with some minor low motor response on the right peroneal nerve, but everything else normal. Needle EMG on the other hand showed multilevel chronic radiculopathy at virtually every site tested, cervical levels and left L4-L5 (only the left side of my body was tested). Left First Digital Interosseous showed decreased motor units. My hands and forearms are weak and a mildly atrophied, the left worse than the right, and heelwalking on my left foot causes a mild foot drop. These areas are consistent with the findings on the EMG. I did have one doctor suggest thoracic outlet syndrome as I have diminished pulses and numbness when raising the arms above the head, as well as elongated transverse processes on my C7 vertebra. But this does not account for the overall weakness, failure to recover fully after 5 years, or the fasciculations, weakness and parasthesias in other parts of the body. Things seem to have a waxing and waning pattern, getting somewhat better for several months, and then getting worse. Reflexes in arms are diminished, reflexes in knees are absent. With the exception of my spine muscles, the muscles in the rest of my body are not spastic, but are instead kind of flaccid, especially in my arms. I do have esophageal spams which cause difficultly swallowing sometimes, but at other times not. So technically I have difficulty swallowing, but since it is not constant I think this is a red herring. My tongue is normal size and does not seem to be atrophied. I have not been able to detect any abnormal movements in my tongue when looking at it in the mirror. My ability to stand is limited to about two twenty minute time periods during the day with many shorter walks to kitchen or bathroom. Total out of bed time is about 3-4 hours per day. Morning activity makes me profoundly fatigued and takes hours to recover from. Recently have had tremors in hands when fatigued, only while trying to use them, never when resting. Workups for Lupus and Rhuematoid arthitis were negative. Total cholesterol is 140, LDH =90 and HDL = 30. These seems to be genetically low, since I have never taken any meds to get them like this. Testosterone is low. Problems: Morbid Obesity 330lbs, hypertension, Mild LVH (1mm), SVT, Gerd, prediabetes, Factor V Leiden. Meds=carvedilol, amlodipine, benadryl, ranitidine, pantoprazole, valerian, lorazepam approx 1-2 times per week, vitamin d, fish oil, vitamin b12 (blood levels are normal). QUESTION: what is the differential diagnosis for the weakness, fasciculations, parasthesias and EMG changes? I need some avenues to pursue, since I've not gotten any real answers from my existing medical team.
I've had a problem for the last 6-8 years or so which I've yet to get addressed. In 2013 I developed severe back pain from the top to the bottom of the spine. Spasms in back muscles only, and fasciculations, parasthesias and pain in both arms and both legs as well as pectorals and latissimus dorsi. Fasciculations also in sternocleidomastoid muscles, chin, eye and trapezius (i.e. cranial nerves). Parasthesias but not actual complete numbness. Also some parasthesias at the time in the genital region. Sensation was preserved everywhere to light touch and pinprick, except that light touch causes pain in the hands. My operative assumption at the time was that this was a back problem. Brain MRI showed nothing of note. Full spine MRI done in 2015 showed mild degenerative changes which were age-appropriate, but no compression which would explain these problems, and no myopathy. No significant central stenosis, only mild foraminal stenosis in a few sites, and no listhesis on dynamic flexion or extension views. A neurologist and two back specialists confirmed that in their opinion this could not be cause by the back. I became almost bed bound for about 4 months, wheelchair bound for a year, and have never regained my strength since then. GBS was suggested at the time, but no spinal tap was done. NCS/EMG in 2015 showed essentially normal NCS with some minor low motor response on the right peroneal nerve, but everything else normal. Needle EMG on the other hand showed multilevel chronic radiculopathy at virtually every site tested, cervical levels and left L4-L5 (only the left side of my body was tested). Left First Digital Interosseous showed decreased motor units. My hands and forearms are weak and a mildly atrophied, the left worse than the right, and heelwalking on my left foot causes a mild foot drop. These areas are consistent with the findings on the EMG. I did have one doctor suggest thoracic outlet syndrome as I have diminished pulses and numbness when raising the arms above the head, as well as elongated transverse processes on my C7 vertebra. But this does not account for the overall weakness, failure to recover fully after 5 years, or the fasciculations, weakness and parasthesias in other parts of the body. Things seem to have a waxing and waning pattern, getting somewhat better for several months, and then getting worse. Reflexes in arms are diminished, reflexes in knees are absent. With the exception of my spine muscles, the muscles in the rest of my body are not spastic, but are instead kind of flaccid, especially in my arms. I do have esophageal spams which cause difficultly swallowing sometimes, but at other times not. So technically I have difficulty swallowing, but since it is not constant I think this is a red herring. My tongue is normal size and does not seem to be atrophied. I have not been able to detect any abnormal movements in my tongue when looking at it in the mirror. My ability to stand is limited to about two twenty minute time periods during the day with many shorter walks to kitchen or bathroom. Total out of bed time is about 3-4 hours per day. Morning activity makes me profoundly fatigued and takes hours to recover from. Recently have had tremors in hands when fatigued, only while trying to use them, never when resting. Workups for Lupus and Rhuematoid arthitis were negative. Total cholesterol is 140, LDH =90 and HDL = 30. These seems to be genetically low, since I have never taken any meds to get them like this. Testosterone is low. Problems: Morbid Obesity 330lbs, hypertension, Mild LVH (1mm), SVT, Gerd, prediabetes, Factor V Leiden. Meds=carvedilol, amlodipine, benadryl, ranitidine, pantoprazole, valerian, lorazepam approx 1-2 times per week, vitamin d, fish oil, vitamin b12 (blood levels are normal). QUESTION: what is the differential diagnosis for the weakness, fasciculations, parasthesias and EMG changes? I need some avenues to pursue, since I've not gotten any real answers from my existing medical team.
Brief Answer:
Differential diagnosis for the weakness, fasciculations, parasthesias
Detailed Answer:
Hi.
Welcome to Ask a doctor.
There may be multiple differential diagnosis of your complaints of fasciculations,fatigue,tremors, weakness and parasthesias.
As the prolapsed inter vertebral disc and compression radiculopathy has been ruled out,the first thing that comes to my mind is amyotrophic lateral sclerosis (ALS).
Gradual onset, progressive muscle weakness is the most common initial symptom in ALS with or with out clumsiness.tripping,poor grips,abnormal fatigue of the arms and/or legs,difficulty in deglutition,muscle cramps and twitches,tremors and uncontrolled emotional outbursts,tongue twitches and difficult speech.
Difficulty walking or doing your normal daily activities of your's point towards it.
But it is often misdiagnosed and often not diagnosed.It is usually confused with MS(Multiple sclerosis) though they have some key differences.
MS is an autoimmune disease that causes your body to attack it's own tissue due to nonrecognition whereas ALS is a nervous system disorder that wears away nerve cells in your brain and spinal cord.Both are treated differently.
Here I want to know that whether your serum PTH.TSH,serum calcium,serum vitamin D3,vitamin B12 and copper levels have been checked(in recent past).
Their deficiencies and altered metabolism also cause same kind of symptoms.How much is your caffeine and alcohol intake?Is there any significant family history?
The proximity of both upper motor neuron and Lower motor neuron structures in the cervical spine makes degenerative myeloradiculopathy,an important diagnostic challenge in cases of suspected ALS.
Repetitive nerve stimulation (RNS) studies and single-fiber EMG (SFEMG) are the electrodiagnostic tests used to confirm the presence of a defect in neuromuscular transmission in Myasthenia gravis,which have been ruled out in your case.
In such patients,I would go for a muscle biopsy to confirm the diagnosis.A lumber puncture(spinal tap) is must to diagnose ALS.
Hope that I have answered your query.If you have other questions and doubts,please let me know.
Stay healthy and blessed.
Regards.
Differential diagnosis for the weakness, fasciculations, parasthesias
Detailed Answer:
Hi.
Welcome to Ask a doctor.
There may be multiple differential diagnosis of your complaints of fasciculations,fatigue,tremors, weakness and parasthesias.
As the prolapsed inter vertebral disc and compression radiculopathy has been ruled out,the first thing that comes to my mind is amyotrophic lateral sclerosis (ALS).
Gradual onset, progressive muscle weakness is the most common initial symptom in ALS with or with out clumsiness.tripping,poor grips,abnormal fatigue of the arms and/or legs,difficulty in deglutition,muscle cramps and twitches,tremors and uncontrolled emotional outbursts,tongue twitches and difficult speech.
Difficulty walking or doing your normal daily activities of your's point towards it.
But it is often misdiagnosed and often not diagnosed.It is usually confused with MS(Multiple sclerosis) though they have some key differences.
MS is an autoimmune disease that causes your body to attack it's own tissue due to nonrecognition whereas ALS is a nervous system disorder that wears away nerve cells in your brain and spinal cord.Both are treated differently.
Here I want to know that whether your serum PTH.TSH,serum calcium,serum vitamin D3,vitamin B12 and copper levels have been checked(in recent past).
Their deficiencies and altered metabolism also cause same kind of symptoms.How much is your caffeine and alcohol intake?Is there any significant family history?
The proximity of both upper motor neuron and Lower motor neuron structures in the cervical spine makes degenerative myeloradiculopathy,an important diagnostic challenge in cases of suspected ALS.
Repetitive nerve stimulation (RNS) studies and single-fiber EMG (SFEMG) are the electrodiagnostic tests used to confirm the presence of a defect in neuromuscular transmission in Myasthenia gravis,which have been ruled out in your case.
In such patients,I would go for a muscle biopsy to confirm the diagnosis.A lumber puncture(spinal tap) is must to diagnose ALS.
Hope that I have answered your query.If you have other questions and doubts,please let me know.
Stay healthy and blessed.
Regards.
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
Brief Answer:
Differential diagnosis for the weakness, fasciculations, parasthesias
Detailed Answer:
Hi.
Welcome to Ask a doctor.
There may be multiple differential diagnosis of your complaints of fasciculations,fatigue,tremors, weakness and parasthesias.
As the prolapsed inter vertebral disc and compression radiculopathy has been ruled out,the first thing that comes to my mind is amyotrophic lateral sclerosis (ALS).
Gradual onset, progressive muscle weakness is the most common initial symptom in ALS with or with out clumsiness.tripping,poor grips,abnormal fatigue of the arms and/or legs,difficulty in deglutition,muscle cramps and twitches,tremors and uncontrolled emotional outbursts,tongue twitches and difficult speech.
Difficulty walking or doing your normal daily activities of your's point towards it.
But it is often misdiagnosed and often not diagnosed.It is usually confused with MS(Multiple sclerosis) though they have some key differences.
MS is an autoimmune disease that causes your body to attack it's own tissue due to nonrecognition whereas ALS is a nervous system disorder that wears away nerve cells in your brain and spinal cord.Both are treated differently.
Here I want to know that whether your serum PTH.TSH,serum calcium,serum vitamin D3,vitamin B12 and copper levels have been checked(in recent past).
Their deficiencies and altered metabolism also cause same kind of symptoms.How much is your caffeine and alcohol intake?Is there any significant family history?
The proximity of both upper motor neuron and Lower motor neuron structures in the cervical spine makes degenerative myeloradiculopathy,an important diagnostic challenge in cases of suspected ALS.
Repetitive nerve stimulation (RNS) studies and single-fiber EMG (SFEMG) are the electrodiagnostic tests used to confirm the presence of a defect in neuromuscular transmission in Myasthenia gravis,which have been ruled out in your case.
In such patients,I would go for a muscle biopsy to confirm the diagnosis.A lumber puncture(spinal tap) is must to diagnose ALS.
Hope that I have answered your query.If you have other questions and doubts,please let me know.
Stay healthy and blessed.
Regards.
Differential diagnosis for the weakness, fasciculations, parasthesias
Detailed Answer:
Hi.
Welcome to Ask a doctor.
There may be multiple differential diagnosis of your complaints of fasciculations,fatigue,tremors, weakness and parasthesias.
As the prolapsed inter vertebral disc and compression radiculopathy has been ruled out,the first thing that comes to my mind is amyotrophic lateral sclerosis (ALS).
Gradual onset, progressive muscle weakness is the most common initial symptom in ALS with or with out clumsiness.tripping,poor grips,abnormal fatigue of the arms and/or legs,difficulty in deglutition,muscle cramps and twitches,tremors and uncontrolled emotional outbursts,tongue twitches and difficult speech.
Difficulty walking or doing your normal daily activities of your's point towards it.
But it is often misdiagnosed and often not diagnosed.It is usually confused with MS(Multiple sclerosis) though they have some key differences.
MS is an autoimmune disease that causes your body to attack it's own tissue due to nonrecognition whereas ALS is a nervous system disorder that wears away nerve cells in your brain and spinal cord.Both are treated differently.
Here I want to know that whether your serum PTH.TSH,serum calcium,serum vitamin D3,vitamin B12 and copper levels have been checked(in recent past).
Their deficiencies and altered metabolism also cause same kind of symptoms.How much is your caffeine and alcohol intake?Is there any significant family history?
The proximity of both upper motor neuron and Lower motor neuron structures in the cervical spine makes degenerative myeloradiculopathy,an important diagnostic challenge in cases of suspected ALS.
Repetitive nerve stimulation (RNS) studies and single-fiber EMG (SFEMG) are the electrodiagnostic tests used to confirm the presence of a defect in neuromuscular transmission in Myasthenia gravis,which have been ruled out in your case.
In such patients,I would go for a muscle biopsy to confirm the diagnosis.A lumber puncture(spinal tap) is must to diagnose ALS.
Hope that I have answered your query.If you have other questions and doubts,please let me know.
Stay healthy and blessed.
Regards.
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
Hello Doctor, than you for your response.
Copper and calcium have not been tested. Everything else, yes. By the way blood tests for Myasthenia came back negative.
Two follow up questions please:
1) Along the line of deficiencies, I was a very heavy drinker until 2013, which I know can cause nutritional/vitamin deficiencies, and immediately thereafter, I went on and have been on very high doses of PPI (pantoprazole) and ranitidine, which can also cause deficiences. Are there any other nutritional deficiences that you can think of that can cause these symptoms, would like to get tested for same.
2) My understanding is that ALS involved lower and upper motor neuron signs. As I mentioned, there is no spasticity, no hyperreflexia (in fact reflexes are absent in knees and almost absent in biceps), jaw reflex is normal, no Babinski sign, and no Hoffman sign. I.e. no signs of upper motor neuron involvement. If this ultimately turns out to be a motor neuron disease, would it not be more likely that it is a lower motor neuron disease, such as Progressive Muscular Atrophy, MMN, or Kennedy's disease?
Copper and calcium have not been tested. Everything else, yes. By the way blood tests for Myasthenia came back negative.
Two follow up questions please:
1) Along the line of deficiencies, I was a very heavy drinker until 2013, which I know can cause nutritional/vitamin deficiencies, and immediately thereafter, I went on and have been on very high doses of PPI (pantoprazole) and ranitidine, which can also cause deficiences. Are there any other nutritional deficiences that you can think of that can cause these symptoms, would like to get tested for same.
2) My understanding is that ALS involved lower and upper motor neuron signs. As I mentioned, there is no spasticity, no hyperreflexia (in fact reflexes are absent in knees and almost absent in biceps), jaw reflex is normal, no Babinski sign, and no Hoffman sign. I.e. no signs of upper motor neuron involvement. If this ultimately turns out to be a motor neuron disease, would it not be more likely that it is a lower motor neuron disease, such as Progressive Muscular Atrophy, MMN, or Kennedy's disease?
Hello Doctor, than you for your response.
Copper and calcium have not been tested. Everything else, yes. By the way blood tests for Myasthenia came back negative.
Two follow up questions please:
1) Along the line of deficiencies, I was a very heavy drinker until 2013, which I know can cause nutritional/vitamin deficiencies, and immediately thereafter, I went on and have been on very high doses of PPI (pantoprazole) and ranitidine, which can also cause deficiences. Are there any other nutritional deficiences that you can think of that can cause these symptoms, would like to get tested for same.
2) My understanding is that ALS involved lower and upper motor neuron signs. As I mentioned, there is no spasticity, no hyperreflexia (in fact reflexes are absent in knees and almost absent in biceps), jaw reflex is normal, no Babinski sign, and no Hoffman sign. I.e. no signs of upper motor neuron involvement. If this ultimately turns out to be a motor neuron disease, would it not be more likely that it is a lower motor neuron disease, such as Progressive Muscular Atrophy, MMN, or Kennedy's disease?
Copper and calcium have not been tested. Everything else, yes. By the way blood tests for Myasthenia came back negative.
Two follow up questions please:
1) Along the line of deficiencies, I was a very heavy drinker until 2013, which I know can cause nutritional/vitamin deficiencies, and immediately thereafter, I went on and have been on very high doses of PPI (pantoprazole) and ranitidine, which can also cause deficiences. Are there any other nutritional deficiences that you can think of that can cause these symptoms, would like to get tested for same.
2) My understanding is that ALS involved lower and upper motor neuron signs. As I mentioned, there is no spasticity, no hyperreflexia (in fact reflexes are absent in knees and almost absent in biceps), jaw reflex is normal, no Babinski sign, and no Hoffman sign. I.e. no signs of upper motor neuron involvement. If this ultimately turns out to be a motor neuron disease, would it not be more likely that it is a lower motor neuron disease, such as Progressive Muscular Atrophy, MMN, or Kennedy's disease?
Also, my understanding of ALS is that once the damage is done, there is no going back. Would not the waxing/waning character of my symptoms go against that. Also my understanding is that ALS does not involve sensory symptoms? (parastherias, etc). Is is this innacurrate?
Also, my understanding of ALS is that once the damage is done, there is no going back. Would not the waxing/waning character of my symptoms go against that. Also my understanding is that ALS does not involve sensory symptoms? (parastherias, etc). Is is this innacurrate?
Brief Answer:
?LMN LESION
Detailed Answer:
Hi...
You need to test for serum calcium, serum vitamin D3, serum electrolytes, blood sugar fasting and PP(to rule out diabetic radiculopathy),VDRL, HIV, PTH (Parathyroid), serum TSH, X-ray cervical spine (to rule out cervical rib),serum vitamin B12 levels and CPK enzyme levels.
Nerve conduction study, electrophysiological profile,needle EMG, muscle biopsy and CSF examination do complete the list.
I totally agree that your drinking habit in the past and multiple comorbidities must have caused multiple deficiencies.
I also agree that it is not a UMN lesion.That has also been excluded by means of your brain scans.
Signs of UMN lesion include weakness, hyperreflexia and increased tone.
Signs of LMN lesions include weakness, atrophy,hyporeflexia or absent reflexes.
It is either pure LMN lesion or ALS.
ALS (Lou Gehrig's disease) is a progressive disorder which disrupts signals to all voluntary muscles and both UMN and LMN are affected.
The thing which is against ALS is that it is always progressive and no waxing and waning of symptoms occur.As far as sensory involvement is concerned,ALS may have sensory involvement due to loss of myelinated fibres and axonal degeneration causing sensory neuropathy.
Outcome in ALS is almost always adverse and clinical diagnosis of ALS is made in setting of a combined UMN and LMN signs and symptoms present in multiple regions of body.
The other differential diagnosis,as you told is,pure LMN Lesion.
That's why I want you to go for the remaining investigations so as to differentiate between a LMN lesion and ALS.This workup will take us out of this diagnostic dilemma.
A lack of family history and lack of bulbar signs is against the diagnosis of XXXXXXX disease.
Hope that I have answered your query.
Stay healthy and stay blessed.
?LMN LESION
Detailed Answer:
Hi...
You need to test for serum calcium, serum vitamin D3, serum electrolytes, blood sugar fasting and PP(to rule out diabetic radiculopathy),VDRL, HIV, PTH (Parathyroid), serum TSH, X-ray cervical spine (to rule out cervical rib),serum vitamin B12 levels and CPK enzyme levels.
Nerve conduction study, electrophysiological profile,needle EMG, muscle biopsy and CSF examination do complete the list.
I totally agree that your drinking habit in the past and multiple comorbidities must have caused multiple deficiencies.
I also agree that it is not a UMN lesion.That has also been excluded by means of your brain scans.
Signs of UMN lesion include weakness, hyperreflexia and increased tone.
Signs of LMN lesions include weakness, atrophy,hyporeflexia or absent reflexes.
It is either pure LMN lesion or ALS.
ALS (Lou Gehrig's disease) is a progressive disorder which disrupts signals to all voluntary muscles and both UMN and LMN are affected.
The thing which is against ALS is that it is always progressive and no waxing and waning of symptoms occur.As far as sensory involvement is concerned,ALS may have sensory involvement due to loss of myelinated fibres and axonal degeneration causing sensory neuropathy.
Outcome in ALS is almost always adverse and clinical diagnosis of ALS is made in setting of a combined UMN and LMN signs and symptoms present in multiple regions of body.
The other differential diagnosis,as you told is,pure LMN Lesion.
That's why I want you to go for the remaining investigations so as to differentiate between a LMN lesion and ALS.This workup will take us out of this diagnostic dilemma.
A lack of family history and lack of bulbar signs is against the diagnosis of XXXXXXX disease.
Hope that I have answered your query.
Stay healthy and stay blessed.
Above answer was peer-reviewed by :
Dr. Raju A.T
Brief Answer:
?LMN LESION
Detailed Answer:
Hi...
You need to test for serum calcium, serum vitamin D3, serum electrolytes, blood sugar fasting and PP(to rule out diabetic radiculopathy),VDRL, HIV, PTH (Parathyroid), serum TSH, X-ray cervical spine (to rule out cervical rib),serum vitamin B12 levels and CPK enzyme levels.
Nerve conduction study, electrophysiological profile,needle EMG, muscle biopsy and CSF examination do complete the list.
I totally agree that your drinking habit in the past and multiple comorbidities must have caused multiple deficiencies.
I also agree that it is not a UMN lesion.That has also been excluded by means of your brain scans.
Signs of UMN lesion include weakness, hyperreflexia and increased tone.
Signs of LMN lesions include weakness, atrophy,hyporeflexia or absent reflexes.
It is either pure LMN lesion or ALS.
ALS (Lou Gehrig's disease) is a progressive disorder which disrupts signals to all voluntary muscles and both UMN and LMN are affected.
The thing which is against ALS is that it is always progressive and no waxing and waning of symptoms occur.As far as sensory involvement is concerned,ALS may have sensory involvement due to loss of myelinated fibres and axonal degeneration causing sensory neuropathy.
Outcome in ALS is almost always adverse and clinical diagnosis of ALS is made in setting of a combined UMN and LMN signs and symptoms present in multiple regions of body.
The other differential diagnosis,as you told is,pure LMN Lesion.
That's why I want you to go for the remaining investigations so as to differentiate between a LMN lesion and ALS.This workup will take us out of this diagnostic dilemma.
A lack of family history and lack of bulbar signs is against the diagnosis of XXXXXXX disease.
Hope that I have answered your query.
Stay healthy and stay blessed.
?LMN LESION
Detailed Answer:
Hi...
You need to test for serum calcium, serum vitamin D3, serum electrolytes, blood sugar fasting and PP(to rule out diabetic radiculopathy),VDRL, HIV, PTH (Parathyroid), serum TSH, X-ray cervical spine (to rule out cervical rib),serum vitamin B12 levels and CPK enzyme levels.
Nerve conduction study, electrophysiological profile,needle EMG, muscle biopsy and CSF examination do complete the list.
I totally agree that your drinking habit in the past and multiple comorbidities must have caused multiple deficiencies.
I also agree that it is not a UMN lesion.That has also been excluded by means of your brain scans.
Signs of UMN lesion include weakness, hyperreflexia and increased tone.
Signs of LMN lesions include weakness, atrophy,hyporeflexia or absent reflexes.
It is either pure LMN lesion or ALS.
ALS (Lou Gehrig's disease) is a progressive disorder which disrupts signals to all voluntary muscles and both UMN and LMN are affected.
The thing which is against ALS is that it is always progressive and no waxing and waning of symptoms occur.As far as sensory involvement is concerned,ALS may have sensory involvement due to loss of myelinated fibres and axonal degeneration causing sensory neuropathy.
Outcome in ALS is almost always adverse and clinical diagnosis of ALS is made in setting of a combined UMN and LMN signs and symptoms present in multiple regions of body.
The other differential diagnosis,as you told is,pure LMN Lesion.
That's why I want you to go for the remaining investigations so as to differentiate between a LMN lesion and ALS.This workup will take us out of this diagnostic dilemma.
A lack of family history and lack of bulbar signs is against the diagnosis of XXXXXXX disease.
Hope that I have answered your query.
Stay healthy and stay blessed.
Above answer was peer-reviewed by :
Dr. Raju A.T
One last question: would the waxing and waning pattern not also go against Progressive Muscle Atrophy, and more towards MMN which is immune-mediated lower motor neuron disease? My understanding is that the damage caused by Progressive Muscle Atrophy does not ever get better once it happens, but is universally progressive? That's not the pattern here.
So does it not make more sense that it is either: 1) nutritional/vitamin/mineral deficiency 2) diabetic neuropathy maybe caused by microvascular changes 3) MMN or CIDP or something similar?
So does it not make more sense that it is either: 1) nutritional/vitamin/mineral deficiency 2) diabetic neuropathy maybe caused by microvascular changes 3) MMN or CIDP or something similar?
One last question: would the waxing and waning pattern not also go against Progressive Muscle Atrophy, and more towards MMN which is immune-mediated lower motor neuron disease? My understanding is that the damage caused by Progressive Muscle Atrophy does not ever get better once it happens, but is universally progressive? That's not the pattern here.
So does it not make more sense that it is either: 1) nutritional/vitamin/mineral deficiency 2) diabetic neuropathy maybe caused by microvascular changes 3) MMN or CIDP or something similar?
So does it not make more sense that it is either: 1) nutritional/vitamin/mineral deficiency 2) diabetic neuropathy maybe caused by microvascular changes 3) MMN or CIDP or something similar?
And by the way I do have much wider than normal transverse processes on my C7 vertebra, and diminished pulses and numbness when raising arms above head. A spine doctor told me that this hints at thoracic outlet syndrome. However this of course does not explain the symptoms/sign in the other parts of the body.
And by the way I do have much wider than normal transverse processes on my C7 vertebra, and diminished pulses and numbness when raising arms above head. A spine doctor told me that this hints at thoracic outlet syndrome. However this of course does not explain the symptoms/sign in the other parts of the body.
Brief Answer:
?LMN LESION
Detailed Answer:
Yes,you are right in that.....the progressive muscular atrophy does not improve with time.
That's why,I am insisting on the fact that your symptomatology does not fall in one category and there is amalgamation and overlapping of symptoms.No copy book diagnosis can be made.After all,medicine is a science of possibilities and keep us guessing all the time.
Of course, it can be a nutritional deficiency and let's hope it is ,so that it is very much salvageable and once the nutrient is replenished,the symptoms would improve.
Thoracic outlet syndrome too ,would not be able to explain all the symptoms of yours.
Please go for the work up and revert thereafter.
Wishing you the best.
?LMN LESION
Detailed Answer:
Yes,you are right in that.....the progressive muscular atrophy does not improve with time.
That's why,I am insisting on the fact that your symptomatology does not fall in one category and there is amalgamation and overlapping of symptoms.No copy book diagnosis can be made.After all,medicine is a science of possibilities and keep us guessing all the time.
Of course, it can be a nutritional deficiency and let's hope it is ,so that it is very much salvageable and once the nutrient is replenished,the symptoms would improve.
Thoracic outlet syndrome too ,would not be able to explain all the symptoms of yours.
Please go for the work up and revert thereafter.
Wishing you the best.
Above answer was peer-reviewed by :
Dr. Raju A.T
Brief Answer:
?LMN LESION
Detailed Answer:
Yes,you are right in that.....the progressive muscular atrophy does not improve with time.
That's why,I am insisting on the fact that your symptomatology does not fall in one category and there is amalgamation and overlapping of symptoms.No copy book diagnosis can be made.After all,medicine is a science of possibilities and keep us guessing all the time.
Of course, it can be a nutritional deficiency and let's hope it is ,so that it is very much salvageable and once the nutrient is replenished,the symptoms would improve.
Thoracic outlet syndrome too ,would not be able to explain all the symptoms of yours.
Please go for the work up and revert thereafter.
Wishing you the best.
?LMN LESION
Detailed Answer:
Yes,you are right in that.....the progressive muscular atrophy does not improve with time.
That's why,I am insisting on the fact that your symptomatology does not fall in one category and there is amalgamation and overlapping of symptoms.No copy book diagnosis can be made.After all,medicine is a science of possibilities and keep us guessing all the time.
Of course, it can be a nutritional deficiency and let's hope it is ,so that it is very much salvageable and once the nutrient is replenished,the symptoms would improve.
Thoracic outlet syndrome too ,would not be able to explain all the symptoms of yours.
Please go for the work up and revert thereafter.
Wishing you the best.
Above answer was peer-reviewed by :
Dr. Raju A.T
Thank you very much for your excellent and thorough responses.
Thank you very much for your excellent and thorough responses.
Brief Answer:
?LMN LESION
Detailed Answer:
Yes.
it is either: 1) nutritional/vitamin/mineral deficiency 2) diabetic neuropathy maybe caused by microvascular changes or 3) MMN because the waxing waning symptoms can not be explained in any other way.This is a strong correlation with above mentioned diagnosis.
Regards
?LMN LESION
Detailed Answer:
Yes.
it is either: 1) nutritional/vitamin/mineral deficiency 2) diabetic neuropathy maybe caused by microvascular changes or 3) MMN because the waxing waning symptoms can not be explained in any other way.This is a strong correlation with above mentioned diagnosis.
Regards
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
Brief Answer:
?LMN LESION
Detailed Answer:
Yes.
it is either: 1) nutritional/vitamin/mineral deficiency 2) diabetic neuropathy maybe caused by microvascular changes or 3) MMN because the waxing waning symptoms can not be explained in any other way.This is a strong correlation with above mentioned diagnosis.
Regards
?LMN LESION
Detailed Answer:
Yes.
it is either: 1) nutritional/vitamin/mineral deficiency 2) diabetic neuropathy maybe caused by microvascular changes or 3) MMN because the waxing waning symptoms can not be explained in any other way.This is a strong correlation with above mentioned diagnosis.
Regards
Note: For further queries, consult a joint and bone specialist, an Orthopaedic surgeon. Book a Call now.
Above answer was peer-reviewed by :
Dr. Vaishalee Punj
Answered by
Get personalised answers from verified doctor in minutes across 80+ specialties
