Question Title: Leg Weakness with Pain - New Info

Forum: Neurology Forum
Topic: Pain

Posted by CCF Neurosurgery MD on January 31, 1998 at 10:24:49:

In Reply to: Leg Weakness with Pain - New Info posted by John Gibson on January 30, 1998 at 20:45:03:

: Dr. Kalfas & Staff:

I last communicated with you on 1/24/98 regarding our daughter's mysterious leg dysfunction. Here's the latest:
On January 20th we visited Dr. Peter Huttenlocher at U of Chicago Hospitals for another opinion. He initially felt she had signs of RSD, but wanted to review her films before making more comments. His review concluded her films are normal, as we have been told by Children's Memorial and our local hospital. He now feels she has RSD and has prescribed intensive physical therapy as well as an anti-depressant called amitriptyline. He feels the basis for her problem is psychological.

We have done some research on RSD, and as I indicated in my e-mail of 1/24, she surely doesn't have many of the common RSD symptoms. Her symptoms are basically two: she has classic sciatic pain down the back of her left leg, causing sharp pain during straight-leg raise, achey-pain along the sciatic nerve that comes & goes, etc. She's been taking neurontin since late November for the pain, and she thinks it helps. But we surely wouldn't call her pain "debilitating." More of a nuisance.. Her other, more overriding symptom, is the dysfunction of her left leg - virtually all her muscles from the hip down don't seem to work. Yet her reflexes are good, and she has passed two EMGs just fine.

She now has mono, and our family doctor had a test done to look for antibodies in her blood (to determine how long it looks like the mono virus has been in her system). He feels, with test results back today, that she's had it for maybe six months! Her original back injury from cheerleading was in late August of 1997. Can there be a connection here? Could the virus have set off her condition, not unlike Guillain-Barre? She had a spinal tap, and I think part of that test is to look for Guillain-Barre. She had a test for Epstein-Barr, and that was negative.
We don't know what to do now. Could this be psychological? Do you think an antidepressant will help? Could she have RSD without the classic symptoms of burning pain (doesn't have any of that), hair and fingernail problems (none of that), discoloration at the site of injury (never had that), etc. Dr. Huttenlocher wanted to send her to a pain clinic initially! Pain is the least of her worries! And we understand that RSD gets worse with time. Again, she is essentially unchanged since inception of symptoms. If anything, she is dealing with her condition better - able to get around more easily, etc.

Atrophy is setting in now - her left leg is only about 90% in diameter compared to her right. We get frantic thinking that as time goes by, we are missing opportunities to get corrective treatment (we understand that with RSD, time is very important - especially in the early stages).

As always, we surely appreciate your comments. We get considerably better responses (and faster!) from you that from anyone else here in Chicago.

Thanks in advance - John

Dear Mr. Gibson:

After posting last night's message to you, I have had the opportunity to review once more all of your previous messages and the information that you have provided. In brief you have told me that;
1. MRI is normal
2. EMG is normal twice
3. Spinal tap is normal
4. Neurological exam is normal except for some mild atrophy
5. pain symptoms are not debilitating

Given all these facts (if the tests were done and interpreted by well qualified physicians), I believe that the likelihood of your daughter having RSD is very small. In fact her atrophy at 10% compared to the other leg is probably related to disuse of the leg. If this were RSD, she would have likely had much more significant atrophy even within a month from the onset of symptoms. If the atrophy were related to RSD, her EMG should almost always show abnormalities.

Now there is a condition found especially in the adolescent and young adult females known as conversion disorder. This is a psychological problem usually trigerred by a major stressful event but manifests itself by organic rather that psychological symptoms. The patients typically are not aware of the psychological component of this illnessa and they are not malingering (faking the symptoms). She does not control the symptoms. Treatment for this problem involves seeing an adolescent psychiatrist or a psychiatrist with special interest in chronic pain. The prognosis for this problem is usually good.

I hope that this information will help with her problem. Please do not hesitate to write back.

Good Luck !!

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