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Foot drop following lumbar disc herniation/Pie caido luego de Hernia del Nucleo Pulposo Lumbar.

Introduction

Foot drop is a tibialis anterior muscle weakness, frequently caused by lower motor neuron disease (1). It's usually unilateral and associated with fibular nerve palsy due to fibular head mechanical compression (2).

The authors present a foot drop case associated with lumbar discopathy.

Case report

A 38-year-old man showed with a 3-month history of right foot weakness. Neurological examination findings: right inferior extremity claudication during gait, right-sided muscle strength impairment (++/++++) and a L3-dermal territory hypoesthesia on his right leg. Lumbar CT and MRI revealed a L3-L4 central extruded herniated disc (Figure 1). The patient was submitted to lumbar L3-L4 hemilaminectomy and extruded herniated disc excision. Motor physiotherapy and orthesis on the right foot were also performed, with recovery after 3 months of therapy.

Discussion

Foot drop or tibialis anterior muscle weakness is caused by multiple neurological conditions such as brain lesion (3,4), spinal cord disease (5), multiple sclerosis (6), common fibular nerve mononeuropathy (2) and degenerative lumbar vertebral diseases (7,8,9,10,11). Foot drop related to lumbar disc herniation or spinal canal stenosis has been considered rare (8,9,10,12,13).

Common causes include L5 radiculopathy caused by disc herniation or spinal canal stenosis and fibular nerve neuropahy (3). Other causes include periphereal nervous system axonal demyelination: conus medularis, cauda equina, nervous plexus and peripheral nerves. Foot drop has been reported in 52 - 67% of the patients with upper motor neuron disease, with the following topographies: interhemispheric motor cortex (expansive or arterior cerebral artery lesions), corona radiata, internal capsule and spinal cord (mielopathy).

[FIGURE 1 OMITTED]

Lesions situated in the interhemispheric Assure may be clinically manifested by paracentral lobule uni or bilateral signs, such as lower limb paresis, usually beginning in one extremity and progressively spreading to the opposite limb (3). Ocasionally, there's also association with focal motor or sensory seizures beginning in the foot, urinary or fecal incontinence and mental changes of the frontal lobe syndrom. Parasagital Meningeom is the brain tumor which mostly presents with foot drop. A central lesion can be suspected in patients with upper motor neuron signs such as positive Babinski's sign, hyperreflexia or clonus. These types have been called spastic foot drop (4).

Radiologically the herniated disc is big, central and rarely paramedian located. L4-L5 and L5-S1 localized herniated discs can commonly cause cauda equina compression (14,15,16). In our case the disc herniation was compressing the L3 root. Foot drop may present as acute, subacute or chronic (14,15,16,17,18). Our patient had a chronic evolution due to a poor access to specialized medical care. Foot drop is considered a neurosurgical emergency (14,15,16,17). Our patient was submitted to a lumbar hemilaminectomy and had a slow evolution. Motor physiotherapy and orthesis where both necessary. EMG, CT, mieloCT and MRI should be performed in order to investigate foot drop as a result of lower motor neuron lesion. Early surgical procedure is associated with good prognosis. Due to poor access to specialized medical care, our patient showed slow recovery, however with good case resolution.

Recibido: 06 de junio 2013

Aceptado: 10 de agosto de 2013

References

(1.) Westhout FD, Pare LS, Linskey ME. Central causes of foot drop: rare and underappreciated differential diagnoses. J Spinal Cord Med 2007; 30: 62-66.

(2.) Katirji MB, Wilbourn AJ. Common peroneal mononeuropathy: a clinical and electrophysiologic study of 116 lesions. Neurology 1988; 38: 1723-1728.

(3.) Baysefer A, Erdogan E, Sali A, Sirin S, Seber N. Foot drop following brain tumors: case report. Minim Invas Neurosurg 1998; 41: 97-98.

(4.) Eskandary H, Hamzei A, Yasamy MT. Foot drop following brain lesion. Surg Neurol 1995; 43: 89-90.

(5.) Tokuhashi Y, Matsuzaki H, Uematsu Y, Oda H. Symptoms of thoracolumbar junction disc herniation. Spine 2001; 26: E512-E518.

(6.) Gilchrist RV, Bhagia SM, Lenrow DA, Chou LH, Chow D, Slipman CW. Painless foot drop: an atypical etiology of a common presentation. Pain Physician 2002; 5: 419-421.

(7.) Andersson H, Carlsson CA. Prognosis of operatively treated lumbar disc herniations causing extensor paralysis. Acta Chir Scand 1966; 132: 501-506.

(8.) Aono H, Iwasaki M, Ohwada T, Okuda S, Hosono N, Fuji T. Surgical outcome of drop foot caused by degenerative lumbar diseases. Spine 2007; 32: E262-E266.

(9.) Garrido E, Rosenwasser R. Painless foot drop secondary to lumbar disc herniation: report of two cases. Neurosurgery 1981; 8: 484-486.

(10.) Girardi FP, Cammisa FP, Huang RC, Parvataneni HK, Tsairis P Improvement of preoperative foot drop after lumbar surgery. J Spinal Disord Tech 2002; 15: 490-49.

(11.) Pritchett JW. Lumbar decompression to treat foot drop after hip arthroplasty. Clin Orthop Relat Res 1994; 303: 173-177.

(12.) Guigui P Benoist M, Delecourt C, Delhoume J, Deburge A. Motor deficit in lumbar spinal stenosis: a retrospective study of a series of 50 patients. J Spinal Disord 1998; 11: 283-288.

(13.) Iizuka Y, iizuka H, Tsutsumi S, Nakagawa Y, Nakajima T, Sorimachi Y, Ara T, Nishinome M, Seki T, Shida K, Takagishi K. Foot drop due to lumbar degenerative conditions: mechanism and prognostic factors in herniated nucleus pulposus and lumbar spinal stenosis. J Neurosurg Spine 2009; 10: 260-264.

(14.) Bartel RHMA, de Vires J. Hemi-cauda equina syndrome from herniated lumbar disc: a neurosurgical emergency? Can J Neurol Sci 1996; 23: 296-299.

(15.) Chang HS, Nakagawa H, Mizuno J. Lumbar herniated disc presenting with cauda equine syndrome. Long term follow up of four cases. Surg Neurol 2000; 53: 1005-1008.

(16.) Jennet W. A study of 25 cases of compression of the cauda equina by prolapsed intervertebral disc. J Neurol Neurosurg Psychiatr 1956; 19: 109-116.

(17.) Mahapatra AK, Gupta PK, Pawar SJ, Sharma RR. Sudden bilateral foot drop. Na unusual presentation of lumbar disc prolapse. Neurol India 2003; 51: 71-72.

(18.) Shapiro S. Cauda equina syndrome secondary to lumbar disc herniation. Neurosurgery 1993; 32: 743-747.

Correspondencia a:

Prof. Dr. Carlos Umberto Pereira

Av. Augusto Maynard, 245/404

Bairro Sao Jose

49015-380 Aracaju- Sergipe

E-mail umberto@infonet.com.br

Carlos Umberto Pereira [1], Guilherme Lepski [2], Breno Jose Alencar Pires Barbosa [3]

[1] Neurosurgeon. Departament Medicine Federal University of Sergipe. Aracaju, Sergipe, Brazil.

[2] Neurosurgeon. Neurosurgery Division of Hospital das Clinicas. University of Sao Paulo, Brazil.

[3] Medical Student. Federal University of Pernambuco. Recife, Brazil.

Rev. Chil. Neurocirugia 40:34-36, 2014
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Article Details
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Title Annotation:Reporte de Casos
Author:Pereira, Carlos Umberto; Lepski, Guilherme; Barbosa, Breno Jose Alencar Pires
Publication:Revista Chilena de Neurocirugia
Date:Jan 1, 2014
Words:1037
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