Consult - History and Physical
Lumbosacral Polyradiculopathy
Description: Briefly, the patient has alumbosacral polyradiculopathy that is temporally related to theepidural anesthesia given to her in October of 2017.
HISTORY OF PRESENT ILLNESS: The patient is a35-year-old woman who reports that on the 30th of October 2017, shehad a rupture of her membranes at nine months of pregnancy, and wasadmitted to hospital and was given an epidural anesthetic. I do nothave the records from this hospital admission, but apparently theepidural was administered for approximately 14 to 18 hours. She wassitting up during the epidural.
She did not notice any difference in her lower extremities at thetime she had the epidural; however, she reports that she wasextremely sleepy and may not have been aware of any change instrength or sensation in her lower extremities at that time. Shedelivered on the 31st of October, by Cesarean section, because shehad failed to progress and had pyrexia.
She also had a Foley catheter placed at that time. On the 1st ofNovember 2017, they began to mobilize her and it was at that timethat she first noticed that she could not walk. She was aware thatshe could not move her legs at all, and then within a few days, shewas aware that she could move toes in the left foot but could notmove her right foot at all. Since that time, there has been agradual improvement in strength to the point that she now haslimited movement in her left leg and severely restricted movementin her right leg. She is not able to walk by herself, and needsassistance to stand. She was discharged from hospital after theCesarean section on the 3rd of November. Unfortunately, we do nothave the records and we do not know what the discussion was betweenthe anesthesiologist and the patient at the time of discharge. Shewas then seen at Avery Hospital on November 05, 2017. She had anMRI scan of her spine, which showed no evidence of an abnormality,specifically there were no cord changes and no evidence of ahematoma. She also had an EMG study at that time by Dr. Xavier,which was abnormal but not diagnostic and this was repeated againin December. At the present time, she also complains of a pressurein both her legs and in her thighs. She complains that her rightfoot hurts and that she has some hyperesthesia there. She has beentaking gabapentin to try to reduce the discomfort, although she ison a very low dose and the effect is minimal. She has no symptomsin her arms, her bowel and bladder function is normal, and herbulbar function is normal. There is no problem with her vision,swallowing, or respiratory function.
PAST MEDICAL HISTORY: Unremarkable except as notedabove. She has seasonal allergies.
CURRENT MEDICATIONS: Gabapentin 300 mg b.i.d.,Centrum once a day, and another multivitamin.
ALLERGIES: She has no medication allergies, butdoes have seasonal allergies.
FAMILY HISTORY: There is a family history ofdiabetes and hypertension. There is no family history of aneuropathy or other neurological disease. She has one child, a son,born on October 31, 2017.
SOCIAL HISTORY: The patient is a civil engineer,who currently works from home. She is working approximately halftime because of limitations imposed on her by her disability, needto attend frequent physical therapy, and also the needs of lookingafter her baby. She does not smoke and does not drink and has neverdone either.
GENERAL PHYSICAL EXAMINATION:
VITAL SIGNS: P 74, BP 144/75, and a pain score of 0.
GENERAL: Her general physical examination was unremarkable.
CARDIOVASCULAR: Normal first and second heart sound, regular pulsewith normal volume.
RESPIRATORY: Unremarkable, both lung bases were clear, andrespiration was normal.
GI: Unremarkable, with no organomegaly and normal bowelsounds.
NEUROLOGICAL EXAM:
MSE: The patient's orientation was normal, fund of knowledge wasnormal, memory was normal, speech was normal, calculation wasnormal, and immediate and long-term recall was normal. Executivefunction was normal.
CRANIAL NERVES: The cranial nerve examination II through XII wasunremarkable. Both disks were normal, with normal retina. Pupilswere equal and reactive to light. Eye movements were full. Facialsensation and strength was normal. Bulbar function was normal. Thetrapezius had normal strength.
MOTOR: Muscle tone showed a slight increase in tone in the lowerextremities, with normal tone in the upper extremities. Musclestrength was 5/5 in all muscle groups in the upper extremities. Inthe lower extremities, the hip flexors were 1/5 bilaterally, hipextensors were 1/5 bilaterally, knee extension on the right was 1/5and on the left was 3-/5, knee flexion was 2/5 on the right and3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 onthe left, foot plantar flexion was 4-/5 on the right and 4+/5 onthe left, toe extension was 0/5 on the right and 4-/5 on the left,toe flexion was 4-/5 on the right and 4+/5 on the left.
REFLEXES: Reflexes in the upper extremities were 2+ bilaterally. Inthe lower extremities, they were 0 bilaterally at the knee andankles. The abdominal reflexes were present above the umbilicus andabsent below the umbilicus. The plantar responses were mute. Thejaw reflex was normal.
SENSATION: Vibration was moderately decreased in the right greattoe and was mildly decreased in the left great toe. There was asensory level to light touch at approximately T7 posteriorly andapproximately T9 anteriorly. There was a range of sensation, butclearly there was a decrease in sensation below this level but notcomplete loss of sensation. To pain, the sensory level is even lessclear, but appeared to be at about T7 on the right side. In thelower extremities, there was a slight decrease in pin and lighttouch in the right great toe compared to the left. There was noevidence of allodynia or hyperesthesia. Joint position sense wasmildly reduced in the right toe and normal on the left.
COORDINATION: Coordination for rapid alternating movements andfinger-to-nose testing was normal. Coordination could not be testedin the lower extremities.
GAIT: The patient was unable to stand and therefore we were unableto test gait or Romberg's. There was no evidence of focal backtenderness.
REVIEW OF OUTSIDE RECORDS: I have reviewed therecords from Avery Hospital, including the letter from Dr. Yansenand the EMG report dated 12/17/2017 from Dr. Xavier. The EMG reportshows evidence of a lumbosacral polyradiculopathy belowapproximately T6. The lower extremity sensory responses areessentially normal; however, there is a decrease in the amplitudeof the motor responses with minimal changes in latency. I do havethe MRI of lumbar spine report from 11/06/2017 with and withoutcontrast. This showed a minimal concentric disc bulge of L4-L5without disc herniation, but was otherwise unremarkable. Thepatient brought a disc with a most recent MRI study; however, wewere unable to open this on our computers. The verbal report isthat the study was unremarkable except for some gadoliniumenhancement in the lumbar nerve roots. A Doppler of the lowerextremities showed no evidence of deep venous thrombosis in eitherlower extremity. Chest x-ray showed some scoliosis on the lumbarspine, curve to the left, but no evidence of other abnormalities. ACT pelvis study performed on November 07, 2017 showed somenonspecific fluid in the subcutaneous fat of the back, posterior toL4 and L5 levels; however, there were no pelvic masses or otherabnormalities. We were able to obtain an update of the report fromthe MRI of the lumbar spine with and without contrast dated12/30/2017. The complete study included the cervical, thoracic, andlumbar spine. There was diffuse enhancement of the nerve roots ofthe cauda equina that had increased in enhancement since prior examin November. It was also reported that the patient was givenintravenous methylprednisolone and this had had no effect onstrength in her lower extremities.
IMPRESSION: The patient has a condition that istemporally related to the epidural injection she was given at theend of October 2017, prior to her Cesarean section. It appears shebecame aware of weakness within two days of the administration ofthe epidural, she was very tired during the epidural and may havemissed some change in her neurological function. She was severelyweak in both lower extremities, slightly worse on the right thanthe left. There has been some interval improvement in her strengthsince the beginning of November 2017. Her EMG study from the end ofDecember is most consistent with a lumbosacral polyradiculopathy.The MRI findings of gadolinium enhancement in the lumbar nerveroots would be most consistent with an inflammatory radiculitismost likely related to the epidural anesthesia or administration ofthe epidural. There had been no response to IV methylprednisolonegiven to her at Avery. The issue of having a lumbar puncture tolook for evidence of inflammatory cells or an elevated protein hadbeen discussed with her at both Avery and by myself. The patientdid not wish to consider a lumbar puncture because of concerns thatthis might worsen her condition. At the present time, she is ableto stand with aid but is unable to walk. There is no evidence onher previous EMG of a demyelinating neuropathy.
RECOMMENDATIONS:
The diagnostic issues were discussed with the patient at length.She is informed that this is still early in the course of theproblem and that we expect her to show some improvement in herfunction over the next one to two years, although it is unclear asto how much function she will regain.
She is strongly recommended to continue with vigorous physicaltherapy, and to continue with the plan to mobilize her as much aspossible, with the goal of trying to get her ambulatory. If she isable to walk, she will need bilateral AFOs for her ankles, toimprove her overall mobility. I am not prescribing these because atthe present time she does not need them.
We discussed increasing the dose of gabapentin. The paresthesiasthat she has may indicate that she is actually regaining somesensory function, although there is a concern that as recoverycontinues, she may be left with significant neuropathic pain. Ifthis is the case, I have advised her to increase her gabapentindose from 300 mg b.i.d. gradually up to 300 mg four times a day andthen to 600 mg to 900 mg four times a day. She may need otherneuropathic pain medications as needed. She will determine whetherher current symptoms are significant enough to require thisincrease in dosage.
The patient will follow up with Dr. Yansen and his team at AveryHospital. She will also continue with physical therapy within theAvery system.
Questions (One to two pages, please):
1. In a paragraph or two, write a complete explanation to thepatient and her family, in lay terms, telling them what hashappened and what the likely outcome will be.
