Focal motor weakness and recovery following chronic subdural hematoma evacuation.

OBJECTIVE: The incidence of chronic subdural hematomas (cSDHs) is expected to climb precipitously in the coming decades because of the aging populous. Neurological weakness is one of the most common presenting neurological symptoms of cSDH. Yet, the recovery rates of motor strength recovery are seldom documented, as neurological outcomes have predominantly focused on broader functional assessment scores or mortality. In this study, the authors performed one of the first detailed analyses on functional motor weakness and recovery in patients who underwent cSDH evacuation. METHODS: Patients who underwent evacuation of a cSDH at a tertiary academic medical center between November 2013 and December 2021 were retrospectively identified using ICD-9 and ICD-10 billing codes. The presence of focal motor weakness was subcategorized by location as upper extremity (UE) or lower extremity (LE). Postoperative improvement, worsening, or resolution of weakness was recorded at the time of discharge. Statistical analysis included univariate and backward stepwise multivariable logistic regression modeling. RESULTS: A total of 311 patients were included in the analysis. Patients were significantly more likely to experience UE weakness than LE weakness (29% vs 18%, p < 0.001). Forty-one percent (43/104) had both UE and LE weakness present. Risk factors for the development of focal motor weakness at the time of presentation were older age (OR 1.02, p = 0.03), increased cSDH size (OR 1.04, p = 0.02), and the presence of a unilateral cSDH (OR 2.32, p = 0.008). The majority of patients (68%, 71/104) experienced motor strength improvement following cSDH evacuation, with 58% (60/104) having complete resolution of weakness. Multivariable logistic regression analysis revealed that longer symptom duration was associated with lower rates of improvement (OR 0.96, p = 0.024). Older age was also associated with reduced resolution of weakness (OR 0.96, p = 0.02). CONCLUSIONS: This study represents one of the first in-depth analyses investigating the rates of motor strength weakness and recovery following cSDH evacuation. Nearly two-thirds of all patients had complete resolution of their weakness by the time of discharge, and more than three-quarters had partial improvement. Risk factors for impaired neurological recovery were longer symptom duration prior to treatment and older age.

Preoperative motor weakness and the impact on patient reported outcomes in lateral lumbar interbody fusion.

This study measures the impact of preoperative motor weakness (MW) on Patient-Reported Outcome Measures (PROMs) in lateral lumbar interbody fusion (LLIF) patients. Retrospectively-sourced data from a prospectively-maintained, single-surgeon database created two cohorts of LLIF patients: patients with/without documented MW. Demographics/perioperative characteristics/PROMs were collected preoperatively and at six-weeks/final follow-up (FF). Studied outcomes were Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), 12-Item Short Form (SF-12) Physical/Mental Component Score (PCS/MCS), Patient Health Questionnaire (PHQ-9), Visual Analog Scale Back/Leg Pain (VAS-BP/LP), and Oswestry Disability Index (ODI). Multivariable linear/logistic regression calculated/compared intercohort minimum clinically important difference (MCID). Mean postoperative follow-up time was 11.5 ± 7.52 months. In total, 214 LLIF patients from December 2010 to May 2023 were included, with 149 having documented MW. In Table 1, self-reported gender was significant between cohorts (p < 0.025). Other significant demographic characteristics were smoker status (p < 0.002), diabetes (p < 0.016), and CCI score (p < 0.011). Table 2 shows notably significant perioperative characteristics: spinal pathology (degenerative spondylolisthesis/foraminal stenosis/herniated nucleus pulposus) (p < 0.005, all), estimated blood loss/length of stay/postoperative day (POD)-zero narcotic consumption (p < 0.001, all). Table 3 outcomes/MCID achievement percentages demonstrated insignificant intercohort differences besides a weakly significant FF ODI score (p < 0.036). MW, a frequently reported symptom in spine surgery, is poorly studied in LLIF patients. Thus, this study evaluates MW impact on PROMs and notes no significant differences. However, one exception regarding FF disability scores was recorded. MW did not affect MCID achievement for our patient population. Therefore, the preliminary findings suggest preoperative MW imparts minimal influence on PROMs/MCID in LLIF patients.

Ankle and toe weakness caused by calcified ligamentum flavum cyst: A case report.

BACKGROUND: Ligamentum flavum cysts, which are most common in mobile junctional levels of the spine, can be a rare cause of spinal stenosis. There have been several case reports of ligamentum flavum cysts. However, there is yet to be a documented case report of a calcified ligamentum flavum cyst. Herein, we report the first case of a calcified ligamentum flavum cyst causing ankle and toe weakness. CASE SUMMARY: A 66-year-old male visited our hospital complaining of claudication as well as thigh and calf pain in his left leg, all beginning two weeks prior. Physical examination revealed motor weakness of the left ankle dorsiflexion and great toe dorsiflexion. Lumbar spinal computed tomography scans showed spinal stenosis combined with a calcified mass at the left side of the L4-5 level. Magnetic resonance imaging showed dural sac compression caused by the calcified mass at the left ligamentum flavum of the L4-5 level. We performed decompressive laminectomy and excision of the calcified mass combined with posterior lumbar interbody fusion at the L4-5 level. Intra-operatively, we found a firm and nodule like mass originating from the ventral surface of ligamentum flavum. Pathological examination suggested a calcified pseudocyst without a capsular lining. After the operation, the patient's motor weakness in the ankle and great toe improved gradually. CONCLUSION: The patient's ankle and great toe weakness were improved successfully after surgical removal of the calcified cyst.

Dengue and Hypokalemic Paralysis: A Rare Association.

Dengue is one of the most common mosquito-borne viral illnesses in tropical areas, including Pakistan. Presentation varies from a self-limiting flu-like illness to life-threatening conditions like hemorrhagic shock and multi-organ dysfunction leading to death. In the absence of vomiting and diarrhea, electrolyte abnormalities are rare findings. Though Guillain-Barré syndrome is a known association of viral illnesses presenting with flaccid paralysis, there is a possibility for dengue to cause hypokalemia without apparent gut or renal losses. Dengue-associated hypokalemic paralysis is an underrecognized entity but has a favorable outcome. The clinician should suspect this in patients presenting with motor weakness in dengue-endemic areas. Neurological complications of dengue are reported frequently now, so early recognition of these neurological manifestations is needed for the successful recovery of patients. Here, we discuss a case of dengue-induced hypokalemia presenting with acute flaccid paralysis.

Insight into adult-onset metachromatic leukodystrophy with optic atrophy: A comprehensive case report.

This abstract provides an overview of metachromatic leukodystrophy (MLD), an autosomal recessive disorder stemming from arylsulfatase A deficiency. MLD leads to cerebroside sulfate accumulation, causing central and peripheral demyelination. Clinical manifestations vary by age group: late-infantile (rapid progression), juvenile (slower progression), and adult-onset (psychiatric symptoms). A case study details a 23-year-old with progressive vision impairment, motor weakness, and cognitive changes. Examination and MRI findings led to suspicion of MLD, later confirmed by enzyme testing. Optic nerve involvement is emphasized, along with diagnostic criteria involving enzyme assays, imaging, and urinary sulfatide excretion tests. While no cure exists, symptomatic and supportive care, including hematopoietic stem cell transplantation, remains key in MLD management.

Beyond the Ordinary: An Atypical Guillain-Barré Syndrome Case With Unique Characteristics.

We present a patient with pharyngeal-cervical-brachial Guillain-Barré syndrome (PCB-GBS) that progressed to a severe state followed by a quick recovery after treatment. This unique clinical course has not been documented previously and provides a potentially invaluable description of a novel GBS variant. A 42-year-old man arrived at the emergency department with a 24-hour history of dysphagia, weakness in his right arm, and bilateral shoulder weakness. Nerve conduction velocity testing revealed bilateral sensory and motor polyneuropathy, leading to the diagnosis of GBS with the PCB variant. Timely diagnosis and plasmapheresis treatment contributed to a complete recovery of muscle strength and reflexes. In cases resembling ours, it is imperative to contemplate the existence of rare Guillain-Barré variants. This case underscores the necessity of recognizing and addressing rare Guillain-Barré variants in clinical settings with similar presentations.

Sporadic Hemiplegic Migraine.

An uncommon presentation of a migraine headache is hemiplegic migraine, which can clinically imitate other conditions including transient ischemic attacks and stroke with unilateral muscle weakness or hemiplegia. We present a 46-year-old female patient who was admitted with symptoms of a unilateral occipital headache, dysphagia and left-sided motor weakness. Diffusion magnetic resonance imaging (MRI) and brain tomography results were normal. A diagnosis of sporadic hemiplegic migraine was made after extensive workup and managed conservatively with solumedrol. The patient was discharged on prednisone and tetrahydrozoline ophthalmic solution with a drastic improvement in symptoms. On a follow-up visit, there was a complete resolution of symptoms.

Nocturnal Leg Cramps and Lumbar Spinal Stenosis: A Cross-Sectional Study in the Community.

Purpose: Nocturnal leg cramps are considered to be a symptom of lumbar spinal stenosis (LSS). However, the relationship between LSS and nocturnal leg cramps in the general population remains unclear. The purpose of this study was to investigate the prevalence and characteristics of nocturnal leg cramps in LSS in the community. Patients and Methods: 328 voluntary participants were enrolled in this study. The presence of LSS was assessed by a validated and self-administered diagnostic support tool. The presence of nocturnal leg cramps and neurological findings were evaluated by one experienced spine surgeon. To investigate the relationship between leg cramps and anatomical factors, the participants underwent an MRI scan, and the dural sac cross-sectional area (DCSA) at each lumbar intervertebral disc level was measured. Results: A total of 214 participants (65.2%) had nocturnal leg cramps, and 94 of 328 participants (28.7%) showed typical LSS symptoms. In the typical LSS symptom group, 31 participants (33.0%) had nocturnal leg cramps. In the atypical LSS symptom group, 83 participants (35.5%) had nocturnal leg cramps. There was no statistically significant difference in the prevalence of nocturnal leg cramps between the two groups. The narrowest DCSA (<25 mm2 and 25-49.4mm2) was statistically related to the presence of nocturnal leg cramp. Statistically significant differences in sensory disturbance and motor weakness were not observed between the subjects with and those without nocturnal leg cramps. Moreover, impaired PTR was statistically related to the presence of nocturnal leg cramp. Conclusion: The prevalence of nocturnal leg cramps did not differ with or without typical LSS symptoms in the community. The degree of dural tube compression that is determined by DCSA had a direct effect on the presence of nocturnal leg cramps. Neurological impairment, such as PTR abnormalities, was associated with the presence of nocturnal leg cramps.

COVID-19 and Neurologic Manifestations: An Experience at Major New York City Hospitals.

INTRODUCTION: The exact incidence of neurologic manifestations in coronavirus disease 2019 (COVID-19) patients is not clear. The New York City Hospital system has been severely affected by the COVID-19 pandemic between December 2019 and 202. A large number of patients were treated at these centers. This study aims to investigate the incidence of such neurologic manifestations. Secondly, we wanted to find out if there is a correlation between comorbidities and neurologic manifestations in patients with COVID-19. METHODOLOGY: A retrospective analysis of 5,455 Electronic Medical Records of patients with a positive polymerase chain reaction (PCR) result admitted to Elmhurst Hospital, Queens Hospital Center, Jacobi Medical Center, and North Central Bronx Hospitals, four of the 11 teaching hospitals in the NYCHH (New York Health + Hospitals) between 3-1-2020 to 8-31-2020 was carried out. Comprehensive data were collected using medical documentation in five categories: demographic details, comorbidities, symptoms, laboratory findings, and radiologic examinations. All neurologic manifestation keywords were provided to the statisticians by two trained and board-certified physiatrists. Neurologic manifestations were categorized into central nervous system (CNS) manifestations and peripheral nervous system (PNS) manifestations. Results; Out of the 5,455 patients, 285 patients (5.2%) had central nervous system manifestations, a prevalence in people older than 50, and had a high incidence of comorbidities. We found increased D-dimer and high C reactive protein levels. Our findings agree with two of the three authors with significant case volume.

Transverse myelitis after infection with varicella zoster virus in patient with normal immunity: A case report.

BACKGROUND: Varicella zoster virus (VZV) is a human neurotropic and double-stranded DNA alpha-herpes virus. Primary infection with VZV usually occurs during childhood, manifesting as chickenpox. Reactivation of latent VZV can lead to various neurological complications, including transverse myelitis (TM); although cases of the latter are very rare, particularly in newly active VZV infection. CASE SUMMARY: We report here an unusual case of TM in a middle-aged adult immunocompetent patient that developed concomitant to an active VZV infection. The 46-year-old male presented with painful vesicular eruption on his left chest that had steadily progressed to involvement of his back over a 3-d period. Cerebrospinal fluid testing was denied, but findings from magnetic resonance imaging and collective symptomology indicated TM. He was administered antiviral drugs and corticosteroids immediately but his symptom improvement waxed and waned, necessitating multiple hospital admissions. After about a month of repeated treatments, he was deemed sufficiently improved for hospital discharge to home. CONCLUSION: VZV myelitis should be suspected when a patient visits the outpatient pain clinic with herpes zoster showing neurological symptoms.

Severe Motor Weakness Due to Disturbance in Peripheral Nerves Following Tisagenlecleucel Treatment.

BACKGROUND: Neurotoxicity is one of the dangerous complications of chimeric antigen receptor (CAR) T-cell therapy, while its pathophysiology remains to be fully understood. Motor weakness not associated with central nervous system (CNS) toxicity has rarely been reported after CAR T-cell therapy. CASE REPORT: A 42-year-old female with a refractory diffuse large B-cell lymphoma received tisagenlecleucel (tisa-cel) and developed cytokine release syndrome (CRS) on day 3. She was treated with tocilizumab and methylprednisolone, which resolved CRS promptly. On day 7, motor weakness in lower extremities appeared, and she gradually became unable to walk without showing any other symptoms attributed to CNS disturbances. Whereas dexamethasone and tocilizumab were ineffective, neuropathy improved after high dose chemotherapy followed by autologous stem cell transplantation. Nerve conduction study (NCS) in lower extremities showed a decline in compound muscle action potential amplitude along with worsening of motor weakness, which was restored after improvement of symptoms. Based on symptoms and NCS, her motor weakness was thought to be due to disturbance in peripheral nerves. CONCLUSION: This study reports a patient who developed severe motor weakness due to disturbance in peripheral nerves after tisa-cel therapy. Neurotoxicity of non-CNS origin should also be noted in CAR T-cell therapy.

Mobility Improvements After a High-cadence Dynamic Cycling Intervention in an Individual with Motor Neuron Disease: A Case Study.

Previous exercise studies in individuals with motor neuron disease have shown some positive benefits but the stress of regular exercise could result in overuse weakness in this population. The purpose of this case study is to determine the efficacy, and tolerability of a high-cadence dynamic cycling intervention in an individual with motor neuron disease. A 67-year-old male with significant lower extremity weakness and a diagnosis of idiopathic motor neuron disease completed six 30-minute sessions of high cadence dynamic cycling over a two-week period using a custom-built motorized ergometer with the motor speed set at 80 revolutions per minute. This intervention resulted in an 80.4 m increase in walking distance during the six-minute walk test (21% increase), with a lower rating of perceived exertion than at baseline. Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised scores improved slightly (2.4%) suggesting that the intervention was tolerated, and it did not compromise the participant's physical function. These data show that this intervention can improve mobility, is well-tolerated and minimizes the risk of overuse weakness in an individual with motor neuron disease.

The impact of preoperative motor weakness on postoperative opioid use after ACDF.

This study aims to determine if preoperative weakness is an isolated risk factor for prolonged postoperative opioid use after anterior cervical discectomy and fusion (ACDF). Patients with preoperative weakness were significantly more likely to have prolonged and inappropriate opioid use and have a single prescription mean morphine equivalent (MME) ≥ 200. Logistic regression isolated preoperative weakness, opioid tolerance, depression, and VAS Neck pain as independent predictors of extended opioid use. High postoperative opioid dose (MME ≥ 90) correlated with opioid tolerance, younger age, male sex, greater CCI, prior cervical surgery, and preoperative VAS Neck pain on regression.

Spinal cord injury by direct damage during trigger point injection: a case report.

Trigger point injection (TPI) is commonly administered for myofascial pain syndrome management, but occasionally leads to complications, including bleeding, muscle hematoma, vasovagal syncope, skin infections, and pneumothorax. This report presents a case of TPI-induced iatrogenic spinal cord injury (SCI). A 59-year-old woman received TPI for myofascial pain on both thoracolumbar paraspinal muscles. She experienced an electric shock sensation throughout the lower extremities upon receiving blind TPI in the left thoracolumbar paraspinal muscle, and later complained of weakness (manual muscle test grade: 0-2) and neuropathic pain (numeric rating scale [NRS]: 7) in the lower left extremity. Thoracolumbar magnetic resonance imaging (MRI) 3 days after the TPI revealed a high-intensity T2 signal in the left T12 to L2 spinal cord segments, indicating the presence of edema or inflammation in this region. In concordance with the MRI findings, electrophysiological recordings performed 11 days after the TPI revealed no central motor conduction time response in the left leg. At 7 months post-onset, the patient had partially recovered motor function and neuropathic pain was reduced to NRS 4. Clinicians should be aware of the possibility of needle-induced SCI during paraspinal muscle TPI; imaging guidance may be helpful for accurate needle targeting during the procedure.

Neuralgic amyotrophy: an underrecognized entity.

Neuralgic amyotrophy (NA) is markedly underdiagnosed in clinical practice, and its actual incidence rate is about 1 per 1000 per year. In the current article, we provide an overview of essential information about NA, including the etiology, clinical manifestations, diagnostic investigations, differential diagnosis, treatment, and prognosis. The causes of NA are multifactorial and include immunological, mechanical, or genetic factors. Typical clinical findings are a sudden onset of pain in the shoulder region, followed by patchy flaccid paralysis of muscles in the shoulder and/or arm. A diagnosis of NA is based on a patient's clinical history and physical examination. Gadolinium-enhanced magnetic resonance imaging and high-resolution magnetic resonance neurography are useful for confirming the diagnosis and choosing the appropriate treatment. However, before a diagnosis of NA is confirmed, other disorders with similar symptoms, such as cervical radiculopathy or rotator cuff tear, need to be ruled out. The prognosis of NA depends on the degree of axonal damage. In conclusion, many patients with motor weakness and pain are encountered in clinical practice, and some of these patients will exhibit NA. It is important that clinicians understand the key features of this disorder to avoid misdiagnosis.

An optimal epidural catheter placement site for post-cesarean section analgesia with double-space technique combined spinal-epidural anesthesia: a retrospective study.

BACKGROUND: Epidural anesthesia affects lower extremities, which often prevents early mobilization postoperatively. The incidence of numbness and motor weakness in the lower extremities with respect to epidural catheter placement site in cesarean section (CS) is uncertain. We aimed to investigate the effect of catheter placement site on postoperative lower extremities numbness and motor weakness in patients who received combined spinal-epidural anesthesia (CSEA) for CS including analgesic effects and optimal epidural placement site in CS. METHODS: We retrospectively included 205 patients who underwent CS with CSEA at the University of Tsukuba Hospital between April 2018 and March 2020, and assessed numbness and motor weakness in the lower extremities. We also examined whether differences in the intervertebral space of epidural catheter placement and epidural effect on the lower extremities are related to analgesic effects. ANOVA and Mann-Whitney U test were used for statistical analysis. RESULTS: The incidence of numbness and motor weakness were 67 (33%) and 28 (14%), respectively. All patients with motor weakness had numbness. A more caudal placement was associated with increased incidence of affected lower extremities. There was no significant difference in the analgesic effect depending on the catheter placement site. When the lower extremities were affected, the number of additional analgesics increased (p < 0.001). Patient-controlled epidural analgesia was used for fewer days in patients with motor weakness (p = 0.046). CONCLUSION: In CS, epidural catheter placement at T10-11 or T11-12 interspace is expected to reduce effect on the lower extremities and improve quality of postoperative analgesia.

Surgical outcomes and factors related to postoperative motor and sensory deficits in resection for 244 cases of spinal schwannoma.

In a large cohort the clinical presentation, management and outcomes of spinal schwannoma and factors related to postoperative motor and sensory deficits were invesgtigated. In 244 patients (males: 126, females: 118, average age 51.8 y) at one center, significant factors related to postoperative motor and sensory deficits were identified. Tumors were in the cervical (n = 79, 32.4%), lumbar (n = 66), thoracolumbar (T11-L1) (n = 55), and thoracic (n = 39) regions, and 5 patients had sacrum tumors. The rates of postoperative motor and sensory deterioration were 13.1% and 20.5%, respectively. The risk factors for motor deterioration were preoperative motor weakness, preoperative gait disturbance, dumbbell Eden type II, subtotal resection, and operative time, and those for postoperative sensory deficit were preoperative gait disturbance and subtotal resection. Of 12 patients with significant TcMEP changes, 11 had a new motor deficit after surgery; and of 216 patients with stable TcMEP data, 196 were neurologically intact after surgery (true negative) and 20 (11.0%) had deficits in the immediate postoperative stage (false negative). These deficits resolved during hospitalization for most patients. Of 15 patients with TcMEP deterioration and recovery, 11 (93.3%) had no motor deficits after surgery (p < 0.01).

Two Cases of Posterior Cerebral Artery P2 Segment Occlusion with Motor Weakness Improved by Acute Mechanical Thrombectomy.

BACKGROUND: Clinical evidence to support the use of mechanical thrombectomy (MT) for posterior cerebral artery P2 segment occlusion (P2O) has not been established, and hemiplegia due to P2O improved by MT to our knowledge has not yet been reported. We report 2 cases of P2O with hemiplegia improved by MT. CASE DESCRIPTION: In case 1, a 68-year-old man was admitted with right hemiplegia and dysesthesia (National Institutes of Health Stroke Scale score 14). Head magnetic resonance imaging showed acute ischemia in the left inferolateral thalamus and posterior limb of the internal capsule. Angiography showed left P2O, which was recanalized after MT. Hemiplegia improved immediately following recanalization, and modified Rankin Scale score at discharge was 0. In case 2, a 69-year-old man was admitted with left hemiplegia and dysesthesia (National Institutes of Health Stroke Scale score 8). Head magnetic resonance imaging showed acute ischemia in the right inferolateral thalamus and posterior limb of the internal capsule. Angiography showed right P2O, which was recanalized after MT, as in case 1. His symptoms resolved completely. CONCLUSIONS: P2O may cause severe motor deficit. In such cases, MT may contribute to safely improving patients' deficits.

Postherpetic abdominal pseudohernia: An uncommon complication of herpes zoster.

Herpes zoster, a common inflammatory viral disease, results in several complications. Pain and sensory disorders are the main symptoms of herpes zoster. We reported a case of segmental abdominal zoster with progression to motor involvement and pseudohernia.

Selective Hand Motor Cortex Lesions Masquerading as "Pseudoperipheral Nerve Palsy".

Strategic cortical lesions involving the hand motor cortex (HMC) presenting acutely as distal upper limb pure motor weakness certainly do need to be differentiated on clinical grounds from "pseudoperipheral palsy." This rare phenotype can imitate peripheral motor nerve deficits and should not be easily overlooked. The isolated "central hand and finger weakness" presenting as an acute onset of varying combinations such as pseudomedian, pseudoradial, and/or pseudoulnar nerve palsy is intriguing to the novice. In literature, this phenotype has been reported solely to result from cortical cerebral infarction and documented to occur in <1% of all ischemic strokes. The apropos of six "unforgettable patients" here highlights the heterogeneous pathophysiologic etiologies and mechanisms that included not only the conventional stroke risk factors but also hyperhomocysteinemia, common carotid artery thrombosis due to hyperhomocysteinemia and severe iron-deficiency anemia, biopsy-proven giant cell arteritis (GCA), cerebral metastasis, and dilated cardiomyopathy-related left ventricular thrombosis. Physicians and neurologists alike, as clinicians, need to be familiar with the peculiarities and clinical presentations of central hand control network cortical lesions.