Cases for Discussion
Case #1: Highest level gait disorder?
This 84-year-old man was referred for deteriorating gait and memory, beginning 3-5 years ago. These problems began insidiously and progressed gradually. Throughout this time, he had been sleeping in a Lazy Boy chair because of chronic low back pain. He now walks with a walker. Carbidopa-levodopa 25/100 two tablets tid did not help. Exam revealed orientation to place but not time. Recall was 0 of 3 words. He could not spell WORLD backward and could not draw intersecting pentagons. He was mildly bradykinetic and had mild paratonia in all four limbs. His speech was mildly slow and hypophonic. Gait is shown.
Case #2: Numb clumsy hands and a "drunken gait"
Two months ago, this 59-year-old woman began noticing numbness and tingling in both hands and neck pain radiating into both upper limbs. One week ago, she began walking "like a drunk". She had no symptoms above the neck, and bowel and bladder control was normal. She has a 20-year history of low back pain and is status post three lumbar laminectomies. Examination revealed mildly clumsy fine finger movements, finger-nose-finger movement and heel-knee-shin movement. Vibration sensation was absent in the feet and mildly impaired in the fingers, bilaterally. Proprioception was mildly impaired in the fingers and toes, bilaterally. She had no knee or ankle reflexes. Gait is shown.
Case #3: Unsteady gait and "falls like a log"
This 72-year-old man complains of poor balance and falling. He has had hypertension since age 30. Two years ago, he noticed unsteadiness when walking on a golf course. He balance gradually deteriorated, and he has repeatedly fallen backward during the past year. In the past few months, he has fallen virtually every day. His steps have become short, and he has an occasional tendency to freeze when crossing thresholds and turning. His gait is particularly bad when walking in crowded rooms. His family has noticed considerable variability in his gait. There are times when he gets out of a chair and walks relatively normally, but at other times, he may require assistance. He has become forgetful and has had urinary urgency but no incontinence. Carbidopa-levodopa 25/100 tid did not help. His MMSE score was 15 (disoriented to time, recall 0/3, could not spell WORLD backwards, missed one step of the 3-step command, poor intersecting pentagons). Gait is shown.
LP opening pressure = 11 cm. 30 cc removed. He stopped falling for several days. Repeat MMSE = 20.
VP shunt ---> MMSE = 22. Stopped falling.