Walking Difficulty in a middle-aged man …

Difficulty in walking may be secondary to a disorder in the joints, muscles, peripheral nerves, or a central cause.

This is a story of our patient who presented with vertigo and walking difficulty for the past six months.

This patient has no comorbid conditions like Diabetes, Hypertension, or Cardiovascular diseases.

He noticed that while walking, he sometimes lose his balance. Over the past two months, his condition worsened and he would fall after losing his balance.

He attributed this to vertigo and was being treated with vestibular sedatives like betahistine but had little relief.

He denied any history of numbness or paraesthesias. There is no history of any focal weakness or loss of consciousness.

The patient denied any history of headache, vomiting or double vision.

Examination of the patient with walking difficulty …

General physical examination is unremarkable except for the early greying of hair. He seemed aged than his actual age.

Neurological examination is presented here in the videos…

The above video was recorded when the patient was asked to walk a straight line with the toes touching the back of the front foot. This is called a “tandem walk”. 

Did you notice that the patient can not perform the “tandem walk test”.

This is the heel to shin test. The patient is asked to lift the leg and slide it down the contralateral leg from the shin downwards.

The test is positive when the patient can not perform it and become ataxic. The heel to shin test is done to test coordination.

This is Dysdiadochokinesia. This test is performed by asking the patient to perform rapid alternating movements with one hand.

Inability to perform rapid alternating movements is termed as Dysdiadochokinesia.

There was no focal weakness or loss of sensations.

Cranial nerves were intact.

The rest of the systemic examination was also unremarkable.

He was investigated …

Blood CBC was normal

Blood chemistry was also unremarkable.

Thyroid profile was normal but Vitamin B 12 levels were below the lower limits of the normal range.

MR imaging of the brain was performed that revealed bilateral cerebellar atrophy.

How should we proceed further?

Date: 24/10/2019

Thanks for all the comments.

I requested a neurologist’s expert opinion. It was a coincidence that the neurologist to whom I referred the patient had seen the patient one year back for the same problem.

One year back he was investigated and found to have a B12 deficiency. He was treated and improved.

So, we started the patient on B 12 injections. After a follow up of about 3 months, his symptoms still persisted.

Another neurologist’s opinion was taken but little was added to his treatment regimen.

Probably, this time he has developed irreversible damage and atrophy that is not improving with B 12 replacement.

How can we help him?

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