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Acute bilateral foot drop with or without cauda equina syndrome-a case series

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  • NHS Lothian, Edinburgh University Hospitals

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Introduction Isolated acute bilateral foot drop due to degenerative spine disease is an extremely rare neurosurgical presentation, whilst the literature is rich with accounts of chronic bilateral foot drop occurring as a sequela of systemic illnesses. We present, to our knowledge, the largest case series of acute bilateral foot drop, with trauma and relevant systemic illness excluded. Methods Data from three different centres had been collected at the time of historic treatment, and records were subsequently reviewed retrospectively, documenting the clinical presentation, radiological level of compression, timing of surgery, and degree of neurological recovery. Results Seven patients are presented. The mean age at presentation was 52.1 years (range 41–66). All patients but one were male. All had a painful radiculopathic presentation. Relevant discopathy was observed from L2/3 to L5/S1, the commonest level being L3/4. Five were treated within 24 h of presentation, and two within 48 h. Three had concomitant cauda equina syndrome; of these, the first two made a full motor recovery, one by 6 weeks follow-up and the second on the same-day post-op evaluation. Overall, five out of seven cases had full resolution of their ankle dorsiflexion pareses. One patient with 1/5 power has not improved. Another with 1/5 weakness improved to normal on the one side and to 3/5 on the other. Conclusion When bilateral foot drop occurs acutely, we encourage the consideration of degenerative spinal disease. Relevant discopathy was observed from L2/3 to L5/S1; aberrant innervation may be at play. Cauda equina syndrome is not necessarily associated with acute bilateral foot drop. The prognosis seems to be pretty good with respect to recovery of the foot drop, especially if partial at presentation and if treated within 48 h.
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ORIGINAL ARTICLE - SPINE DEGENERATIVE
Acute bilateral foot drop with or without cauda equina
syndromea case series
Andreas K. Demetriades
1
&Marco Mancuso-Marcello
1
&Asfand Baig Mirza
2
&Joseph Frantzias
3
&David A. Bell
2
&
Richard Selway
2
&Richard Gullan
2
Received: 25 October 2020 / Accepted: 26 January 2021
#The Author(s) 2021
Abstract
Introduction Isolated acute bilateral foot drop due to degenerative spine disease is an extremely rare neurosurgical presentation,
whilst the literature is rich with accounts of chronic bilateral foot drop occurring as a sequela of systemic illnesses. Wepresent, to
our knowledge, the largest case series of acute bilateral foot drop, with trauma and relevant systemic illness excluded.
Methods Data from three different centres had been collected at the time of historic treatment, and records were subsequently
reviewed retrospectively, documenting the clinical presentation, radiological level of compression, timing of surgery, and degree
of neurological recovery.
Results Seven patients are presented. The mean age at presentation was 52.1 years (range 4166). All patients but one were male.
All had a painfulradiculopathic presentation. Relevant discopathy was observed from L2/3 to L5/S1, the commonest level being
L3/4. Five were treated within 24 h of presentation, and two within 48 h. Three had concomitant cauda equina syndrome; of
these, the first two made a full motor recovery, one by 6 weeks follow-up and the second on the same-day post-op evaluation.
Overall, five out of seven cases had full resolution of their ankle dorsiflexion pareses. One patient with 1/5 power has not
improved. Another with 1/5 weakness improved to normal on the one side and to 3/5 on the other.
Conclusion When bilateral foot drop occurs acutely, we encourage the consideration of degenerative spinal disease. Relevant
discopathy was observed from L2/3 to L5/S1; aberrant innervation may be at play. Cauda equina syndrome is not necessarily
associated with acute bilateral foot drop. The prognosis seems to be pretty good with respect to recovery of the foot drop,
especially if partial at presentation and if treated within 48 h.
Keywords Footdrop .Bilateral footdrop .Acute bilateral footdrop .Cauda equina syndrome .Lumbar stenosis .Lumbar disc
prolapse .Lumbar disc prolapse .Degenerative spine disease .Surgical treatment .Timing of surgery
Introduction
Whilst the presence of slowly progressive bilateral foot drop is
common in chronic systemic conditions, acute foot drop is a
rare clinical presentation and acute bilateral foot drop is even
rarer. An aetiology of degenerative spinal disease is rarer still.
Only 6 cases have been reported in the previous literature [1,
12,20,21,27].
The most common reports of acute bilateral foot drop are
due to bilateral common peroneal nerve palsies [1719,22,
25,36], notably due to iatrogenic compression during surgical
positioning in a range of surgical specialties [2,57,10,13,
16,24,32,33].
We present 7 cases of acute and bilateral foot drop, all due
to degenerative spinal disease, with trauma and relevant sys-
temic illness excluded as causes. We aim to provide insight
into the aetiology of acute bilateral foot drop from degenera-
tive spinal causes and provide a schema with which to ap-
proach this rare, fairly obscure and challenging clinical
presentation.
This article is part of the Topical Collection on Spine degenerative
*Andreas K. Demetriades
andreas.demetriades@gmail.com
1
Department of Neurosurgery, New Royal Infirmary, Edinburgh, UK
2
Department of Neurosurgery, Kings College Hospital, London, UK
3
Department of Neurosurgery, Brighton and Sussex University
Hospital, Brighton, UK
https://doi.org/10.1007/s00701-021-04735-0
/ Published online: 7 February 2021
Acta Neurochirurgica (2021) 163:1191–1198
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Methods
Demographic and radiological data from seven cases of acute
bilateral foot drop which presented to three neurosurgical cen-
tres over a 13-year period were prospectively collected by the
treating surgical team. Complementary data was collected ret-
rospectively. We reviewed patient demographics, clinical pre-
sentation, radiological parameters, and surgical parameters in-
cluding time from presentation to surgery. Preoperative, early
postoperative, and latest follow-up were compared.
Results
The characteristics of each case in the series are shown in
Table 1.
The mean age at presentation was 52.1 years (range 41
66). All patients but one were male. All seven had a
radiculopathic presentation and three of these had concomi-
tant cauda equina syndrome (CES).
Six of the seven cases had less than antigravity power at
presentation: four patients with 1/5 power bilaterally; one with
0/5 power; one with 2/5. The seventh patient had 3/5 power.
All cases had painful foot drop. Two were operated within
48 h of presentation, whereas the remaining five were operat-
ed within 24 h.
Five out of seven cases had full resolution of their ankle
dorsiflexion paresis. One patient with 1/5 power never im-
proved. Another with 1/5 weakness improved to normal on
the one side and to 3/5 on the other.
Only three out ofthe seven cases had concomitant CES; the
levels of compression in the first two cases were L2/3 and L5/
S1, respectively, whilst the final patient had an acute disc
prolapse at L2-3 with concurrent canal stenosis at L4/5.
These are summarised in Fig. 1. The first two had full resolu-
tion of sphincter function, one by the 6 weeks follow-up and
the other on the same-day post-op evaluation; both these have
residual numbness; one of these had residual sexual dysfunc-
tion. The third and most recent patient has had minor improve-
ments overall; however, the follow-up is short thus far and
ongoing.
Discussion
Foot drop is typically defined as significant weakness in ankle
(+/- toe) dorsiflexion [39].
There is a variety of surgical and non-surgical differential
diagnoses, and theoretically, any pathology affecting any part
of the anatomical chain involved in dorsiflexion (brain, spinal
cord, nerve roots, lumbosacral plexus, sciatic nerve, peroneal/
fibular nerve, and the anterior tibialis muscle) may lead to foot
drop.
There are many reports of chronic bilateral foot drop oc-
curring as a sequela of medical illnesses. Endocrine causes
include hypothyroid myositis [9] and diabetic peripheral neu-
ropathy [31] whilst diseases which modulate nutritional intake
such as Anorexia Nervosa [15]andCrohnsdisease[8]have
been implicated too. Moreover, anterior horn cell disease such
as in motor neuron disease [40], neuromuscular junction dis-
ease such as myasthenia gravis [11], peripherally demyelinat-
ing disease such as the Guillain-Barre syndrome [30], and
myopathies such as muscular dystrophy [26] could feasibly
present with a gradual onset bilateral foot drop.
Reports of traumatic brain injury, and an anterior commu-
nicating artery intracranial aneurysm, presenting with acute
bilateral foot drop highlight the need to exclude cranial/
central causes when no other pathology can be found [14,
28,34]. Both the brain and spinal cord could be the source
of the presentation due to specific vascular, neoplastic, infec-
tive, or demyelinating lesions.
The nerve root innervation supplying the tibialis anterior is
predominantly L4 and L5, whilst some EMG studies have
shown small amounts of nerve fibre recruitment from the
L2, L3, S1, and S2 nerve roots [37]. The spectrum of cases
in our series supports this pattern of nerve fibre recruitment.
Our clinical expectation would be that, commonly, a postero-
lateral disc protrusion at the L3/4 or L4/5 levels, or a far lateral
disc protrusion at the L4/5 or the L5/S1 levels, could cause
foot drop. However, acute far lateral disc prolapses are rare
bilaterally.
Of the six bilateral foot drop cases due to degenerative disc
disease in the literature, four were caused by bilateral postero-
lateral disc prolapses at the L4/5 level [1,12,21,27], one at
the L3/4 level [20], and one at the T12/L1 level [12].
Of our seven cases, one was caused by an L2/3 disc pro-
lapse, three at the L3/4 level (commonest), one at L4/5, and
one at L5/S1 disc; one case had compression both at L2/3 and
L4/5 levels. Therefore, the majority of both our cases and
those reported in the literature align with expectation, but there
certainly exist some unexpected disc level prolapses which
may be accounted for by aberrant innervation.
Besides degenerative disc disease, other reported spinal
aetiologies of acute bilateral foot drop include synovial cysts
[3,4] and an intradural haematoma [38]. An intradural tumour
has been implicated in unilateral but not in bilateral foot drop
[35].
Cauda equina syndrome is not necessarily associated with
acute bilateral foot drop. It is interesting that only three out of
the seven reported cases had concomitant cauda equina syn-
drome. This might be initially surprising, because anatomical-
ly a disc prolapse that is big enough to compress the foraminae
bilaterally might be expected to protrude centrally too.
However, there was no cauda equina syndrome in four out
of seven cases; these had bilateral foraminal stenoses but no
central disc prolapses. This is probably related to the presence
1192 Acta Neurochir (2021) 163:1191–1198
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Table 1 Demographic, clinical, and radiological parameters at presentation, and subsequent follow-up
Patient Age Sex Details of presentation Disc level Nature of disc prolapse Pre-op dorsiflexion power
(L, R)
157M8 day history of severe back pain and an electrifying
sensationintherightleg
worsening weakness in both legs for 3 days, worse on
the right than on the left
foot drop for 5 days at presentation
bowel and bladder symptoms
catheterized in hospital
Saddle anaesthesia and a reduced anal sphincter tone
L2-3 Soft and central (1/5,1/5)
242MReduced sensation and weakness of dorsiflexion in
both feet
Reduced mobility
3 weeks of worsening bilateral foot drop
Intermittent paresthesia in right calf and left leg
L4-5 Soft and postero-lateral (1/5,1/5)
345MPresented acutely with severe pain radiating to the
lower limbs and bilateral foot drop
6-day history of right sciatica
3-day history of left sciatica
Past surgical history included L5/S1 discectomy in
1990 due to low-grade lumbar pain and radiation to
lower limbs
L3-4 Soft and postero-lateral (1/5,1/5)
441MPresented acutely with low back pain
Bilateral L5 radiculopathy
Weakness in dorsiflexion slight worse on the right
side
No known previous medical conditions of note
L3-4 Soft and postero-lateral (0-1/5, 0-1/5)
551FPresented acutely with low back pain and bilateral
foot drop
No known previous medical conditions of note
L5-S1 Soft postero-lateral disc herniation +
bilateral lateral recess stenosis
(3/5, 3/5)
663MPresented acutely with bilateral foot drop
No known previous medical conditions of note
L3/4 disc and L3/4-L4/5 lateral
recess stenosis
Soft postero-lateral disc herniation +
bilateral lateral recess stenosis
(2/5, 2/5)
766MSevere acute low back pain radiating down both
lower limbs, predominantly on the left
Developed severe low back pain the day before with
bilateral lower limb weakness and numbness on
soles of the feet leading of a fall due to pain
L2-3 and L4/5 stenosis Soft postero-lateral disc herniation +
bilateral lateral recess stenosis
(1/5, 1/5)
Patient Cauda equina
syndrome
Procedure Time from
presentation
to surgery (hours)
Post-op
dorsiflexion
power
(L, R)
Latest follow-up
(months)
Latest follow-up
dorsi flexion power
(L, R)
Impression at latest
follow-up
1 Yes 48 (1/5, 0/5) 6 (5/5, 5/5) No pain in the lower back or legs
No bladder symptoms
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Table 1 (continued)
L2-3 microdiscectomy and bilateral
lateral recess decompressions via
laminectomy
Difficulty with ejaculation whilst erection
is unaffected
Residual muscle weakness proximally in
the hips, affecting his knee extension
Perianal and perineal numbness
Lower limb numbness
Discharged from follow-up
2 No Bilateral L4/5 microdiscectomy 24 (0/5, 0/5) 9 (5/5, 3/5) Significant improvement of pain
Driving with a right ankle splint
Discharged from follow-up
3 No L3 laminectomy + L3/4
microdiscectomy
and bilateral lateral recess
decompressions
48 (1/5,1/5) 2 (5/5, 5/5) Independently mobilising
Moving his feet independently with no
foot drop
Complains of residual pain and numbness
affecting mainly the right leg
Ongoing issues with mobility (due to
numbness) and posture with ongoing
physiotherapy
Discharged from follow-up
4 No L3/4 microdiscectomy and bilateral
lateral recess decompressions
24 (2/5,1/5) 113 (5/5, 5/5) No difficulty in walking
Full return of power
Reports complete resolution of symptoms
as of 89 months post-op
Discharged from follow-up
5 Yes L5/S1 microdiscectomy via L5
laminectomy and bilateral lateral
recess decompressions
6 (5/5, 5/5) 2 (5/5, 5/5) No weakness
No pain
No sphincter problems
Mild reduction in sensation on the lateral
aspect of the right leg
Discharged from follow-up
6 No L3/4-L4/5 laminectomy and bilateral
lateral recess decompressions and
bilateral L3/4 microdiscectomy
and
foraminotomy
24 (4/5, 4/5) 12 (5/5, 5/5) No pain
No weakness as of 3 months post-op
Discharged from follow-up
7 Yes L2/3 microdiscectomy and
laminectomy
and bilateral lateral recess
decompressions
and L4/5 laminectomy and and
bilateral
lateral recess decompressions
24 (0/5, 0/5) 2 (1/5, 1/5) Improvement in pain
Mild improvement of ankle dorsiflexion
Gluteal and hamstring muscle wasting
No flickers of movement felt with active
gluteal movement
No sphincter improvement
Follow-up ongoing
1194 Acta Neurochir (2021) 163:1191–1198
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of pre-existing narrow lateral recess anatomy, perhaps
allowing an acute on chronic phenomenon.
Of note, five of the seven patients (two in primary care and
three in the emergency department) needed to attend more
than once before any onward referral for investigation was
made. This may reflect some uncertainty amongst non-
specialist colleagues on the frontline, which may be arising
from a lack of clarity within the specialist (i.e., neurosurgical/
spinal) community itself, where the timing of surgery for acute
discogenic foot drop remains a point of discussion [23,29].
We hope that the series presented will help in timely suspicion
and investigation of acute lumbar spine aetiology.
A flow chart illustrating a suggested work-up for bilateral
acute foot drop presentation is shown in Fig. 2. We believe
that such patients ought to undergo surgical decompression of
the nerve roots as soon as possible, to minimise the degree and
duration of damage to the nerve, and hence improve the
chance of recovery. However, neural recovery may be influ-
enced by the presence of concomitant morbidity, including
diabetes, obesity, and peripheral vascular disease.
Limitations The retrospective nature of this report is an obvi-
ous limitation. Could it be that the condition of acute and
bilateral foot drop due to degenerative disc disease is not rare
and may be underreported? One might consider that with uni-
lateral foot drop being a much commoner situation, it may
lower the interest of reporting bilateral cases. Or could it be
that underreporting might be due to the fact that the line of
Fig. 1 Sagittal and axial imaging views of the seven patients with acute bilateral foot drop. In patient 1, where an MRI was contra-indicated, a
myelogramwas performed. The levels affected ranged from L2/3 to L5/S1. The most commonly affected level was L3/4 in threeout of the seven patients
1195Acta Neurochir (2021) 163:1191–1198
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conduct and recommendations for treatment do not differ? In
our view, the reporting of seven cases encountered over 13
years suggests otherwise. Furthermore, the reality of the rarity
of the presentation of acute bilateral foot drop is underlined if
we consider thatbetween the authors, we have been in practice
for a collective of >100 years.
Conclusion
Bilateral foot drop can occur in chronic fashion as a sequela of
systemic disease. However, when bilateral foot drop occurs
acutely, we encourage the consideration of degenerative spi-
nal disease in the differential diagnosis. Communicating this
with colleagues in receiving/referring specialties might be pru-
dent. Relevant discopathy was observed from L2/3 to L5/S1.
The prognosis seems to be pretty good with respect to recov-
ery of the foot drop, especially if partial at presentation and if
treated within 48 h.
Declarations
Ethics approval and consent to participate All procedures performed
were in accordance with the ethical standards of the institutions and with
the 1964 Helsinki declaration and its later amendments. For this type of
study (retrospective analysis), formal consent is not required
Conflict of Interest All authors declare that they have no conflict of
interest.
Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing, adap-
tation, distribution and reproduction in any medium or format, as long as
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vide a link to the Creative Commons licence, and indicate if changes were
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Fig. 2 A flow chart illustrating a
suggested work-up for bilateral
acute foot drop presentation
1196 Acta Neurochir (2021) 163:1191–1198
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... 1,2,3 Although drop foot from lumbar degenerative disease is rare, it can significantly add to the disability of patients suffering from spine disorders. [3][4][5][6][7] In the setting of lower back pain, radiculopathy, and/or incontinence, lumbosacral spine origin must be ruled out in patients presenting with drop foot. ...
... The authors noted that 5 of the 7 patients were seen by frontline providers (PMD and ED) more than once before the referral to a specialist was made, leading to delay in treatment. 5 Other studies report a correlation between higher preoperative muscle strength and higher rate of recovery. ...
Article
Full-text available
Bilateral drop foot secondary to lumbar spinal disease is rarely reported in the literature. In this case report, a 60 year old male presented with acute on chronic weakness in ankle dorsiflexion and urinary/fecal incontinence. He was found to have L5-S1 severe disc degeneration and spinal stenosis. We report on the diagnosis of bilateral drop foot in the setting of lumbar spinal degenerative disease and the operative technique of the modified Bridle procedure.
... A compressive lesion at the T12-L1 level of the spine is believed to cause foot drop as a non-specific neurologic sign; however, bilateral root paralysis is a rare pathologic condition that requires further investigation to correctly manage and treat the patient [4]. A suggested workup for acute bilateral foot drop has been outlined by Demetriades et al. [5]. ...
Poster
Full-text available
Introduction: Foot drop is defined as an inability to dorsiflex and evert at the ankle joint due to weakness of the tibialis anterior muscle. Weakness is defined as a muscle strength test that results in anything less than 3/5. Most conditions of foot drop are related to chronic or progressive conditions rather than acute onset of presentation. Case Presentation: An 84-year-old female presented to the outpatient clinic complaining of difficulty with ambulation due to bilateral lower extremity weakness. Incidentally, a popliteal DVT was discovered, and she was prompted for direct hospital admission. Discussion: Overall, there is limited data in current literature presenting acute bilateral foot drop. Like a case presented by Kertmen et al., we hypothesize that the T12-L1 compressed spinal cord found on our patient’s MRI may have led to bilateral compression of the L5 nerve root, causing acute bilateral foot drop. Treatment for the underlying cause of acute bilateral foot drop has been ill-defined in literature. The decision to pursue surgical intervention is dependent on the patient’s degree of impaired dorsiflexion, Surgical Risk Score, and willingness to undergo extensive surgery. There has been no clinical trial to date that specifically quantifies the efficacy of surgery versus conservative therapy using foot-ankle bracing orthosis for clinical improvement. Peroneus splints are the mainstay of conservative therapy, but they present with disadvantages. Conclusions: Bilateral foot drop with acute onset is a unique and complex clinical presentation that requires a thorough approach to diagnosis and treatment due to their emergent nature. The decision of conservative or surgical management should follow the shared decision making model.
Article
Full-text available
As gluteal augmentation continues to gain in popularity among patients seeking aesthetic enhancements, a thorough knowledge of the postoperative complications associated with this procedure is crucial. This case report concerns a 31-year-old woman who suffered bilateral foot drop secondary to sciatic neuropathy and as a result was wheelchair-bound for several months, following gluteal autologous fat grafting in the Dominical Republic. One year later, the patient had persistent left foot drop and sensory deficits. This is a devastating but seldom reported complication that all plastic surgeons need to be aware of when performing this operation.
Article
The purpose of this study was to investigate the effectiveness of early (<72 h) versus late (≥72 h) decompression surgery after the onset of drop foot caused by root disorder in lumbar degenerative diseases (LDDs). Data were included from 60 patients who underwent decompression surgery for drop foot caused by LDDs, including lumbar disk herniation or lumbar spinal stenosis. The primary outcome was ordinal change in the manual muscle test (MMT) at 2 years follow-up. Secondary outcomes included changes in the Japanese Orthopedic Association's (JOA) score. The early- and late-stage surgery groups included 20 and 40 patients with mean durations from the onset of drop foot to operation of 0.8 days (range, 0-3 days) and 117.1 days (range, 10-891 days), respectively. There was no significant difference (p = 0.33) between the early- and late-stage surgery groups in the improvement of MMT scores to >4 (90% versus 80%, respectively). However, more patients in the early-stage group achieved an MMT score >5 compared with those in the late-stage surgery group (80% versus 45%; p = 0.03). Furthermore, the recovery rate of JOA scores was significantly higher in the early-stage (89.1%) compared with the late-stage surgery group (68.6%; p < 0.001). Early decompression surgery produced better neurological recovery; however, an improvement of >4 in the MMT score was achieved in 80% of cases with late decompression.
Article
Foot drop due to lumbar disc herniation (LDH) is a relatively common finding in spinal practice. Bilateral foot drop (BFD) due to LDH is an extremely rare condition with only a few reported cases. We describe the case of a middle-aged man presenting with a rapid onset BFD with back and leg pain. Urgent MRI revealed an L4-L5 centrally located LDH with bilateral compression of the L5 nerve roots and the cauda equina centrally. About 4 h after presentation surgery was performed adopting a bilateral L4-L5 interlaminar approach and the prolapsed disc was removed. Nine months after surgery, the patient showed a complete recovery of his deficit. We discuss the advantages of this approach in this urgent situation and we compare it with other techniques.
Article
Drop foot is defined as difficulty of dorsiflexion of the foot and ankle due to weak anterior tibial, extensor hallucis longus and extensor digitorum longus muscles. Cauda equina syndrome, local peroneal nerve damage due to trauma, nerve entrapment, compartment syndrome and tumors are common etiologies. A 32-year-old male patient was applied with difficulty in dorsiflexion of both of his toes, feet and ankles after he had squatted in toilette for 6-7 hours (because of his haemorrhoid) after intense alcohol intake 2 weeks before. Acute, partial, demyelinating lesion in head of fibula segment of peroneal nerves was diagnosed by electromyography. This case was reported since prolonged squatting is an extremely rare cause of acute bilateral peroneal neuropathy. This type of neuropathy is mostly demyelination and has good prognosis with physical therapy and mechanical devices, but surgical intervention may be required due to axonal damage. People such as workers and farmers working in the squatting position for long hours should be advised to change their position as soon as the compression symptoms (numbness, tingling) appear.
Article
Background and importance: Foot drop is defined as a weakness in the ankle and foot dorsiflexors. A disruption of the neural pathway starting from the mesial frontal cortex and ending in the peroneal nerve can lead to foot drop. Unilateral foot drop due to lower motor neuron injury is well documented. However, bilateral foot drop due to a central cause is very rare. Clinical presentation: A 29-year-old male presenting with bilateral lower extremity weakness in addition to rigidity. The patient is known to have bipolar disorder and an Anterior communicating artery aneurysm (ACoA) for which he has not followed up. A CTA showed a partially thrombosed 5 mm × 6 mm ACoA aneurysm. The patient underwent placement of flow diverter PED. Conclusion: Central causes of acute bilateral foot drop are rare but should be considered in the differential diagnosis. Thrombo-embolism due to a partially thrombosed aneurysm is a well known phenomenon, all treatment options should be considered keeping in mind the risks associated with the different techniques due to the intra saccular thrombus.
Article
Background: Foot drop is defined as inability to dorsiflex the foot at the ankle joint. Although a well-documented entity with a myriad of causes along the neuraxis, starting from parasagittal intracranial pathologies to peripheral nerve lesions, treatment has always remained uniform (i.e., elimination of the causative pathology. A conservative approach with complete recovery has never been documented with video evidence). Case description: A 74-year-old female presented with dorsiflexion weakness of the left ankle secondary to a prolapsed disk at the L4-5 level. The duration of the foot drop was short (3 days). She was planned for surgery but kept under close observation considering the consistent recovery of the symptoms. To our astonishment she had rapid pain relief in the next 5 days. Motor power improved over 3 weeks, and she had complete recovery in 4 weeks. Video recordings were made to document the improved power at both stages. Conclusions: Spontaneous recovery of complete foot drop is possible, and there is a role for the conservative management even with dense neurologic deficit in cases of lumbar disk herniation. Careful repeated examination is the key for conservative management before jumping to aggressive surgical intervention.
Article
We report a case of excessive weight loss causing bilateral common peroneal nerve entrapment in a 60-year-old patient. The bilateral peroneal involvement suggested a systemic cause. Excessive weight loss during a relatively short period can cause changes in the tissues surrounding the common peroneal nerve and lead to its entrapment in the peroneal tunnel. Our patient underwent successful surgical decompression with significant improvement.
Article
The popularity of bariatric surgery (BS) began to increase due to the dramatic rise in severe obesity in the past decades. Postoperative follow-up after BS is important to avoid possible medical complications. Therefore, medical complications after BS should be well-known and defined. Herein, we present a case of bilateral peroneal neuropathy (PN) developed after successful BS. The patient lost 40 kg during 16 weeks of follow-up. The foot drop developed after 18 weeks after surgery on the left side and than 24 weeks after surgery on the right side. Peroneal neuropathy-associated weight loss is usually unilateral. Bilateral PN with weight loss is uncommon. The rate of weight loss is an important risk factor for PN. This case report highlights the importance of optimal dietary after BS to control the weight loss rate and nutrient deficiency. © 2017 by Turkish Society of Physical Medicine and Rehabilitation.