Arm and Leg Pain

[jaradak]

I was an active, healthy male (42 yrs.) until Jan. 2002 when I injured my back (buldging at L5/S1, L3/L4 and L4/L5 and anular tear at L5/S1).  I continue to have moderate back/bottom pain, but this is NOT my main problem anymore.

In June 2002, I started having problems with my arms and my legs, mainly at night.  During the day, I have a "heaviness" and cold sensitivity in my arms.  During the night, after about 4 hours of sleep, I am awakened with severe throbbing pain in both arms and in my legs (from knee down).  If I move around, the pain temporarily goes away.  

I am seeing a neuro.  who is unable to diagnos.  Blood work, EMG, and cervical MRI have been normal.  Tried Mirapex(for 4 days)for possible RLS with no result.

My questions are as follows:
1)  Do you have any other suggestions that I can explore with my current doctor?
2)  I would like to seek a second opinion at Cleveland Clinic.  Should I schedule an appointment with a general neurologist or a specialist?
3)  Any chance that my arm problems are related to my back? issues

Thanks for your help!

[CCF-Neuro-M.D.-JT]

1.Somatosensory evoked potentials are further tests that can help evaluate the integrity of the sensory nerves in your arm and leg (similar to an EMG nerve conduction study where they shock you and measure the response at different places). BUt if you're thinking about a second opinion here, then I would wait and have your testing done at the Clinic. A formal examination and full history would be important for an accurate opinion. It's also possible that this is not a primary neurological problem and may be due to inadequate blood flow to the limbs, a rheumatological disorder, or it could be related to a sleep disorder as it only occurs at night. Just some thoughts.
2.You can start with a general neurologist, although there is possibly an element of a neuromuscular disorder. Dr. Shields, Levin, CHemali, and Tsao are all very good neuromuscular specialists.
3.Unlikely if the cervical MRI was normal as this is where the nerves from the arm come from. The lumbosacral region supplies the legs.
Good luck.

[Annika]

Dear Jaradak,

You mentioned your lumbar injury, but didn't mention any surgery - so I'm assuming you just had conservative treatment?  Did you have any epidural steroid injections or any other intervention at your lumbar spine?

Unfortunately, there is a class of disorders in which lumbar spine problems can cause problems with the upper parts of the spinal cord.  These are disorders in which something "tacks down" or "tethers" the spinal cord in the lumbosacral spine.  This can happen because of congenital abnormalities (like congential tethered cord, spinal cord tumors, and spina bifida), but it can also happen later in life.  In my case, I have this problem as a result of scarring from surgery to remove a spinal tumor.  There is a general category of disorders called "arachnoiditis" or "arachnoid adhesions", which describes the formation of scar tissue inside the spinal canal (primarily in the web-like arachnoid layer of the spine).  This tends to happen when something allows blood to enter the spinal canal (surgery, trauma, hemorrhage), or when certain foreign substances are injected into the CSF.

When the spinal cord is tethered, one long-term complication can be the formation of a cyst-like hollowing-out within the upper parts of the spinal cord.  This is called a syrinx.  I don't have a syrinx, but I have severe pain in my upper back, down both arms (into the fourth and fifth fingers), muscle wasting in the upper back and neck, weakness, muscle tightness and frequent muscle twitches (fasciculations) in the same distribution as the pain.  The pain is positional, and is worst in all the positions that put a lot of tension on my spinal cord - especially when lying down at night, when my spine stretches out.  It'll be relieved by brief position changes, but comes right back again.  My neurologist and neurosurgeon feel the basic process is the same as that which eventually causes a syrinx to form, and are following me with scheduled MRI's.

I'm not saying that I think you have a syrinx or even an incipient syrinx, but simply that there are known conditions in which a lumbosacral abnormality causes problems in the upper spinal cord.  Admittedly many of these are very rare, but they do happen.  This would not show up on nerve conduction studies or EMG's, since those only evaluate the peripheral nerves.  It often takes a while for a syrinx to show up so that it can be seen on MRI.  Symptoms of early dysfucntion can hang around for quite a while before this.  I am in touch with many people who have had spinal tumors and/or have arachnoid adhesions inside our spinal canals.  Many of us have a variety of upper body symptoms as well, so I'm not an isolated case.  I'm speaking here only as a patient, though.

Good luck,
Annika