Romberg Question

[Krump]

I'm a 59 year old woman who just got a positive Romberg test. I've tried to research what exactly the doctors are looking for and its confusing to me. I've been referred to a neurologist and I have an appt on 4-17-07. Do I need to worry about this?

[Forum-M.D.-SH]

First of all, keep in mind that I am unable to diagnose you because I am unable to examine you, this forum is for educational purposes.
     A romberg test is performed by having the patient stand with feet together and close their eyes.  In a positive test (which is abnormal) the patient is able to stand until they close their eyes and then they topple over.  Normal patients are able to maintain their balance with their eyes closed.  This test is non-specific and does not signify a particular disease, but often points to a lesion in the inner ear/vestibular system or a lesion in the cerebellum/proprioception.  When patients have inner ear problems they often have vertigo (causes a room spinning sensation)  and balance problems.  These problems can be compensated some by visual input (which tells you brain that the world is not spinning,etc), but when the eyes are closed then all sense of balance is lost.  The cerebellum is an area of the brain the functions in balance and coordination of motor movements and certain receptors around the body give the cerebellum infromation on where the limbs are in space (call proprioception).  If there is a lesion in the cerebellum or in the receptors of proprioception then these can also imbalance, ataxia, falls, etc.  This deficit can be partially compensated by visual input and closing the eyes while standing takes this away causing the person to fall.  Common problems affecting the cerebellum/proprioception system include strokes, multiple sclerosis, tumors, etc. and some less common causes include neurosyphillis, fredrichs ataxia, spinal cerebellar ataxias etc.)  If the only problem on your neurologic exam is a positive romberg that means the lesion is fairly slight since its affects are totally compensated by visual input when the eyes are open.
I hope this has been helpful.

[BobbHilton]

Hi,
   Romberg test is a part of Balance (Ability to stand up) and Gait (ability to walk) Physical exam Tests.
In my practice I saw few reports from  general physcians, who were overreading the test result especially in  your age group, with no other findings or even any symptomes.
   Simply, we  stand the patient with feet together and compare swaying with eyes open vs. closed (Its crucial to specify the direction of the sway..e.g to the side, backward only or alternating forward/packward ).
    If  swaying with closed eyes --> implies proprioceptive (the accurate sense of the positions of the joint ) or a subtle vestibular abnormality (Inner ear or a central nervous system).
  Some time I do "Fukuda test" (an MRI of the head with GD, gives a much better answer these days), which is marching in place for 50 steps . Abnormal if he/she deviates close to 90 degrees or more left or right. If abnormal, it reflects a subtle vestibular disorder.

(Note: you should never do these tests on your own , without a trained physcian around to prevent falls and injuries!!!!)

   The differential diagnosis depends on the accompanying symptomes with Romberg ...generally it could be in
   1- the peripheral nerve (Either, Large fiber neuropathy or sensory gangionopathy)
   2-Posterior part of the spinal cord
   3-Central nervous system
your neurologist will  (if you have other findings on examination) try to look for  a possible high bood sugar (a subclinical), or B6 level, a possible  low vitamine B12,  vitamine E level, or thyroid function, any rheumatologic causes like Sjogren disease..ext, any abnormal protiens/or cells in your blood, any latent chronic infection, nerve conduction tests and MRI to R/O any structural lesions.

  Bob

[Deb9637]

First of all Krump, sorry for piggybacking on your issues and response from Bob.....but, seems Bob is knowledgeable and from what I've read -  perhaps a physician....So, Bob....can you look at the posts on 3/21 (3 months post ACDF) and tell me what you think with regards to my pending surgery and IF it may help the surges of pressure in my head and associated neurological issues?  As I stated in my post.....Hopes of eliminating that are the ONLY reason I'm considering this surgery.  Thank you if can offer a comment.....Deb

[BobbHilton]

Hi Deb,
  In the first place, Pseudotumor cerebri (PTC) is a disorder of CSF resorption by the micro( small) vessels and not a disease of CSF circulation, thats why the ventricles (the fluid filled cavity in the brain) are not enlarged or even small.
   If, for some reason, they still think this cervical disc is the cause then they should support their case by a head MRI findings!!
   I think , your entire case of pseudotumor cerebri should be presented in a new post (disscussion) mentioning how and when it was diagnosed , what where the presenting symptomes? your weight? were you taking any medication even hurbal/over the counter? what was the CSF opening pressure, was it measured while you were sitting? on your side? especially  there are reports of increased CSF pressure in patients with chronic daily headaches and no papilledema. Many of these patients have analgesic rebound headaches, or a migraine variant (no clear headache, but fullness in the head/ discomfort)
    There is no role for visual evoked potentials,VEP, in this disorder; they are either falsly positive, or unreliable and remain normal, because like glaucoma, PTC generally spares macular function (i.e., visual acuity, central visual field, and color vision) (so if early central loss, abnormal VEP, is a red flag! I mean we should not think of PTC).
      In PTC, we depend on is Stereoscopic fundus photography  which detect a subtle papilledema, and the follw up is not by a clincal exam b but by  a test "Goldmann or Humphery visual filed"

     The last point, what else apart from Diamox ,did you use? any special diet?
     any  attempt to lose weight?

   Bob

[Deb9637]

I keep trying to get a post in here Bob.....I seem to have lousy timing.....Nevertheless, if you'll induldge me for a few moments, I'll try and start at the beginning.....This all began three years ago.  My head fills with pressure, I am visibly shaking - like tremors that I had no control over - my hearing fades away - there is a whooshing noise in my ears - my depth perception is all out of whack - and I cannot make my legs do what I want them to.....I tend to walk sideways......my arms won't work right - and I have said from Day One - these episodes have always been immediately preceeded by - accompanied by or immediately followed by a VERY stiff neck.....I am sooooo far away and try as I might to remember what happens first - I can't - It just all happens so fast......In 5 - 7 minutes - I'm fine again.  I have no pain when this is going on.....NONE.....Just this astounding pressure in my head and all of this neuro stuff that happens.....The 1st Neurologist put me on Topamax.  After 6 months - nothing had changed - sought a second opinion.....Second Neurologist spared no testing...... MRI's, Blood work - she tested me for everything and discovered in that testing an anti-thrombin 3 deficiency and beta 2 glycoprotein antibody which I now take meds for, there is no MS or Lupus.  Cerebral angiogram revealed nothing.  Lung Xray - then a CT scan - Holter monitor, Stress test, VER test, opthamolic visits, a high speed photo of my eyes - EKG's, EEG's, more MRI's, LP's with opening pressure 32 first time (sitting), and repeated LP's laying down 27 - 32 opening pressures, had two LP's in the hospital using X Ray guidance and perfectly straight line......with a 25 and 27 opening pressure.  All we seemed to find out was I had high opening pressures.  I am 49, female, 5' 11" - weight about 190, which for me is probably a bit heavy - but I am tall and have a large frame.  At the time this began I wasn't taking any meds......not even over the counter ones....no vitamins either.....Don't drink or smoke.  Neuro doc put me on Diamox and it really did alleviate these symptoms - I'd have an occasional "bad head day" but nothing like I do without the Diamox.....She also prescribed KlorCon for potassium......But a couple of severe bouts of kidney stones and the nephrologist recommended discontinuing Diamox and KlorCon......As my previous posts have said - was referred to neurosurgeon for a shunt.  But, he isn't convinced it's PTC.....and sent me back to neurologist who did a cervical and thorasic MRI to rule out a dural tear.....
Cervical MRI findings:
At the C5-6 level, a disk herniation is identified which appears to be central and compresses on the cord centrally in the left paracentral region and is well visualized. The cord is displaced posteriorly and the anterior-to-posterior dimension of the canal measure between 5 and 6mm.  At the C4-5 level, there is a focal disk bulge which in the central location, slightly to the right paracentral region which is also in contact with the cord and the anterior to posterior dimension of the canal measure 7 - 8 mm.  Impression:  Central disk herniation with left paracentral abnormality and canal stenosis with myelopathic signal increase in the cord.  The cord shows slight flattening.  Note there are no features to suggest a dural tear.
Now, when my neurologist read this to me - she was CONVINCED this is the reason for the issues going on in my head.  Back to the neurosurgeon.....and he did Evoked potentials testing which are all abnormal.
Question:  Do you think this surgery will stop the build up of pressure in my head and I will stop having these episodes?  Could the CSF circulation be compromised due to the herniated disks?  Is that possible?
And to answer your last question......no other meds, no special diet, and I've gained about 20 pounds since this all started 3 years ago.....I'm certainly less active....I just have no strength.....
Honestly, I have not much pain or discomfort......not that isn't tolerable anyway......from these herniated disks......I only want whatever is going on in my head to stop.  I absolutely CANNOT function during the 5 - 7 minutes of whatever happens......Thanks again Bob for taking your time to read this.  If I can answer any other questions, please ask.     Deb

[BobbHilton]

1- All the pressure you mentioned are low ones? its not PTC a normal CSF pressure is 50-200mm H2O and in your case its normal up to 250!! ..its spontaneous intracranial hypotension then??  all the symptomes (My head fills with pressure, I am visibly shaking - like tremors that I had no control over - my hearing fades away - there is a whooshing noise in my ears - my depth perception is all out of whack or episodes have always been immediately preceeded by - accompanied by or immediately followed by a VERY stiff neck) ==>fit this diagnosis as well as the search for a dural tear unless you had PTC the due a traumatic tap ? tear ??

2-  The central cord flattening and signal at  the C4-5 level and C5-6 level,+ the canal stenosis  all thes could explain your symptomes of  " I cannot make my legs do what I want them to.....I tend to walk sideways......my arms won't work right" ..any problem passing urine? any pins and needles?
even when you  " I'm certainly less active....I just have no strength" all could easly blamed on the central compression of the disk and you need to focus on that with you neurosurgeon !!!!!
Note: the reason you do not have much pain because the herniation is central and not posteriolateral!!


testing an anti-thrombin 3 deficiency and beta 2 glycoprotein antibody which I now take meds for??

  Bob

[Deb9637]

Bob, once again, Thank You, for the time you given to me.  When I say "opening pressures consistently
25 - 32",  I understand from my Neurologist that means 250 to 320 mm H2O.....
The anti-thromin 3 deficiency and Beta 2 Glycoprotien 1 antibody are being treated with Plavix and a 325 mg Aspirin daily.  I have no issues passing urine....My beverege of choice is water - I consume probably a gallon a day and find myself in the restroom often....so, no issues there!  
Pins and needles.....?  Sometimes, yes in my left hand and arm but nothing like when I was taking Diamox (1000 mg daily - taken all at once)....And when my legs and arms won't work the way I want them to is ONLY during one of the episodes I have.  And honestly, I have NO CONTROL over what they do during an episode.  In fact, I'm barely aware of anything around me - I appear to be in "la la land" during these times.  I will also add that there is no headache accompanying or following these episodes.
My primary question is -

Could the CSF flow be comprimised from these herniated disks?  And do you think the surgery will help with the surges of pressure in my head and these neruological issues?  Do you think the  problem I am having is solely from these herniations?  I am scheduled for surgery Bobb, on April 5th for the ACDF procedure.

[BobbHilton]

Deb,
    As you know, a correct diagnosis is the base for a correct treatment especially the surgical one. I feel, from your description, that your case lack that at least about the PTC.
    After years of medline review, I admit of not hearing about a mean pressure fo the CSF, unles you are talking about a neuro trauma cases in an intensive care with open skull monitoring? even then I doupt the 320?? But, we nevere stop learning and I will be very gratifull if you could get me the reffrence of that from your neurologist , so I could read/analyze it myself.
    We, only look at the opening pressure of the CSF and 250 mmH2O is the top normal level for the hight and weight you mentioned!
    So, if you dont have issues passing urine (like an urgent need to rush to the WC, straining to start , a feeling of incomplete emptying the bladder, or drippling..ext) then I would say that all your symptomes/CSF pressures are inkeeping with INTRACRANIAL HYPOTENSION which could be spontaneous or secondary and even the anti-thromin 3 deficiency and Beta 2 Glycoprotien 1 antibody  which are part of a hyper-coagulable state could be due to this disease , because central venous thrombsis reported as a complication of Intracranial hypotension!..So you need a different approach than the one used for PTC
Back to your questions:
Could the CSF flow be comprimised from these herniated disks? No
And do you think the surgery will help with the surges of pressure in my head and these neruological issues? yes and no
yes, If the central herniation and cord flattening/signal at the C4-5 level and C5-6 level,+ the canal stenosis are significant per the eye  a neuroradiologist and a neurosurgeon because neurologically we are facing a disease could confuse the picture of a cord compression. And yes if they could look directly for a dural tear which is usually at the thoracic level , but rarly could be in the skull bas level!!
Do you think the problem I am having is solely from these herniations? already answered

  Bob