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Chronic Exertional Compartment Syndrome vs. MS (several ?s)
I'm a unwilling sedentary (rather be up and running) 31 y/o female that was finally diagnosed with severe Chronic Exertional Compartment Syndrome last year (pressures in excess of 90 with normal below 15) and had the fascia release. I was able to walk only a few steps in extreme pain before the surgery, and could walk needing only one crutch upon waking up from that surgery. Since that surgery, I've had numbness, tingling, and edema in both legs. One leg healed well and while still has numb spots, it works better than ever. The other leg took 5 months for the surgical incision to close, had foot drop before the surgery, had occasional foot drop after the surgery, and now I can't walk fast again as the leg is acting like the compartment syndrome is back, including the foot drop and ankle collapsing. When the leg is exerted, the symptoms and foot drop are back, the pain continues for a long while after resting, sometimes for days, just like before the first release, and the new compartment pressure is at 28 (normal below 30), after falling (ankle rolled) during the exertional part of the pressure test. The nerve conduction test in the leg shows all minor issues except for a positive "babinski" sign.
The doc thinks something else is going on and sent me to a neuro doc. The neuro doc did the conduction test the first time, and while the leg was sore, it wasn't too bad. The second time I saw the doc, the leg was sore, not too bad. The third time, I could barely walk, and from the pain of the leg, couldn't stand properly. This doc sent me for a spine MRI which found white spots on the brain stem. The doc has now sent me for a battery of tests thinking it's MS plus that I have a seizure going on in the one muscle.
Anyways, the questions: Can the compartment syndrome mimic MS? Would it be a reasonable conclusion that if the single compartment having problems has high-normal pressure (28), versus the other three treated and asymptomatic compartments with normal (7-10), that high-normal may be the compartment syndrome has returned for whatever reason in that single compartment? Can MS cause seizures of one muscle? Do seizures and MS go hand-in-hand? Can the compartment syndrome cause a seizure of that muscle? Can a compartment syndrome cause a positive "babinksi" sign? If the MRI of the brain shows 3-5 white spots, all tiny, is that proof-positive of MS, even if the other tests (VEP and blood tests) and symptoms are negative? Is there a number cut-off in the diagnostic criteria for MS? If you have the feeling the doc is trying to squeeze you into a diagnosis, can you stop the process and go to someone else and be cleared without having to do a spinal tap? Can extreme stress (somewhat worse than what the flight crew experienced going into the Hudson, think going into the Hudson in a plane without being able to see), cause white spots in the brain? Are these white spots anything to worry about, especially if you aren't having any other symptoms of MS except the leg issues?
The doc thinks something else is going on and sent me to a neuro doc. The neuro doc did the conduction test the first time, and while the leg was sore, it wasn't too bad. The second time I saw the doc, the leg was sore, not too bad. The third time, I could barely walk, and from the pain of the leg, couldn't stand properly. This doc sent me for a spine MRI which found white spots on the brain stem. The doc has now sent me for a battery of tests thinking it's MS plus that I have a seizure going on in the one muscle.
Anyways, the questions: Can the compartment syndrome mimic MS? Would it be a reasonable conclusion that if the single compartment having problems has high-normal pressure (28), versus the other three treated and asymptomatic compartments with normal (7-10), that high-normal may be the compartment syndrome has returned for whatever reason in that single compartment? Can MS cause seizures of one muscle? Do seizures and MS go hand-in-hand? Can the compartment syndrome cause a seizure of that muscle? Can a compartment syndrome cause a positive "babinksi" sign? If the MRI of the brain shows 3-5 white spots, all tiny, is that proof-positive of MS, even if the other tests (VEP and blood tests) and symptoms are negative? Is there a number cut-off in the diagnostic criteria for MS? If you have the feeling the doc is trying to squeeze you into a diagnosis, can you stop the process and go to someone else and be cleared without having to do a spinal tap? Can extreme stress (somewhat worse than what the flight crew experienced going into the Hudson, think going into the Hudson in a plane without being able to see), cause white spots in the brain? Are these white spots anything to worry about, especially if you aren't having any other symptoms of MS except the leg issues?
Right now I am suffering with a large array of symptoms that I am sure you went through as well. I have been dealing with all of these for coming on four months now. The kicker is my diagnosis is taking so long because the neurologist "fears it could be ms". I strongly believe that all of these tests I have to go through, checking to see if what I am suffering from is ms, are completely unnecessary. Many people I know that have been diagnosed and treated for chronic exertional compartment syndrome have all said their neurologists believed they were showing early signs of ms and needed to rule that out before continuing on with tests for chronic exertion compartment syndrome. Of course, after all that time and money spent on pricey tests like multiple MRIs ( which with my insurance I would still have to pay $4,325 out of pocket ) and nerve tests, they finally continued on to check if compartment syndrome was indeed what they were suffering from and turns out it was. Then after their procedures all that I have spoken with claim to be doing perfectly fine. I understand MS is a very serious disease and that the symptoms from both MS and chronic exertional compartment syndrome mirror each other in many ways, but I wish they would just flip the diagnosing and test orders. You could argue that they want to check for the more severe of the two diagnosis first ( MS ) but it takes a while in many cases to set up MRIs and the other tests for this, so why not in the mean time do the pressure tests and etc for compartment syndrome? These of course are just my thoughts. I have no medical background and don't claim to have one. I am just a 20 year old college student looking to get back on the lacrosse field for next season.
Thank you for your comments. Your handle is appropriate for this doctor's quest to chase after windmills of a disease.
Very thorough reply and easy to understand. I learned something more about lesions and MS today. Thank you....
Heather
Earth Mother
Heather
Earth Mother
Hi, Welcome and what a list of questions! I am the resident physician here, but I was not a neurologist and am no longer in practice. I can answers some of your questions, make an educated stab at others and not answer the rest.
These are questions rightly put to a neurologist.
"Can the compartment syndrome mimic MS?" - To an extent, yes. The symptoms of pain and weakness can mimic those of MS, but the early testing using the EMGs and pressures would pretty quickly shows that the problem was "peripheral" - meaning that it was outside the Central Nervous System, CNS. All of MS is damage confined within the CNS.
"Would it be a reasonable conclusion that if the single compartment having problems has high-normal pressure (28), versus the other three treated and asymptomatic compartments with normal (7-10), that high-normal may be the compartment syndrome has returned for whatever reason in that single compartment?" - I would say yes, if that pressure is indicative of a compartment syndrome.
"Can MS cause seizures of one muscle?" - I have never heard the term "seizure" used for the spasming of a muscle or muscle group, but it might have been your neuro's way of describing muscle spasms. The answer is Yes, MS can and often does cause paroxysmal spasms of a muscle or muscle groups. What I don't know is whether local injury can also cause the problem. Within MS this kind of spasming is typical of lesions in the spinal cord. Did you have a sinal cord MRI?
"Do seizures and MS go hand-in-hand?" True seizures (those that originate in the brain) can be caused by MS - For the kind of "seizure" spoken of by your neurologist see the above answer.
"Can the compartment syndrome cause a seizure of that muscle?" Compartment syndromes cause pressure necrosis of the nerves and muscles by cutting off the vlood supply due to high pressures. When I was primary surgeon (as an intern) rotating through ortho when I opened up the calf of my patient with a traumatic compartment syndrome, the muscle was pale and purple and twitching, but not spasming. True, spasms? I don't really know.
"Can a compartment syndrome cause a positive "babinksi" sign?" - I would say no. The positive Babinski sign is a sign of spinal cord damage/lesion. That sign is an art to elicit and to interpet. If there is pain in the involved limb it can make the test even harder to do.
" If the MRI of the brain shows 3-5 white spots, all tiny, is that proof-positive of MS, even if the other tests (VEP and blood tests) and symptoms are negative?" - No. There is no MRI pattern that is proof positive of MS. Brainstem lesions are more suggestive of MS than brain lesions, because there are fewer diseases that cause lesions there. The VEP is useful only when it is positive. A negative VEP tell you nothing about whether a person has MS. In MS ALL of the blood tests would be expected to be negative. Those tests are to look for diseases OTHER THAN MS.
"Is there a number cut-off in the diagnostic criteria for MS? " - I assume you mean number of lesions. No.
"If you have the feeling the doc is trying to squeeze you into a diagnosis, can you stop the process and go to someone else and be cleared without having to do a spinal tap?" - ABSOLUTELY! You NEVER need to go through a test about which you are uncomfortable! You have the absolute right at any time to leave the care of a physician in whom you have lost confidence - or even just for another opinion or two.
"Can extreme stress (somewhat worse than what the flight crew experienced going into the Hudson, think going into the Hudson in a plane without being able to see), cause white spots in the brain?" - No. Stress does not cause lesions on the brainstem, spine, nor in the brain.
"Are these white spots anything to worry about, especially if you aren't having any other symptoms of MS except the leg issues?" -- In the true absence of any symptoms or neurologic signs of a problem, most neurologists would not worry and just see you periodically to check for the beginning of any symptoms. You do have a +Babinski. Do you have brisk reflexes or any other positives on a thorough, head-to-toe exam? If not, then a "watch and wait" plan makes sense. If I were the neuro, I would make sure that I had obtained MRIs of the entire CNS, the brain, brainstem and the entire spical cord - and I would order them on a 3T machine. Then I would likely watch and wait.
How important is the LP is what you are also asking. Many docs do not use the LP much at all, and it is not required by the diagnostic guidelines.
We have had a few people come through here with lesions, but no symptoms. In most of them the neuro exam uncovered subtle deficits and the symptoms were often not far behind. But, a certain portion of the population has brain lesions and no neuro disease. Few at your age have them. Brainstem lesions are presumed to indicate a problem. So I see why the neuro is concerned, but I don't see the hurry.
I hope this helps. Please remember that my word is NOT gospel of any kind. My answers are based on my reading and my own experience in medicine in general and not on any vast experience in MS.
Quix
These are questions rightly put to a neurologist.
"Can the compartment syndrome mimic MS?" - To an extent, yes. The symptoms of pain and weakness can mimic those of MS, but the early testing using the EMGs and pressures would pretty quickly shows that the problem was "peripheral" - meaning that it was outside the Central Nervous System, CNS. All of MS is damage confined within the CNS.
"Would it be a reasonable conclusion that if the single compartment having problems has high-normal pressure (28), versus the other three treated and asymptomatic compartments with normal (7-10), that high-normal may be the compartment syndrome has returned for whatever reason in that single compartment?" - I would say yes, if that pressure is indicative of a compartment syndrome.
"Can MS cause seizures of one muscle?" - I have never heard the term "seizure" used for the spasming of a muscle or muscle group, but it might have been your neuro's way of describing muscle spasms. The answer is Yes, MS can and often does cause paroxysmal spasms of a muscle or muscle groups. What I don't know is whether local injury can also cause the problem. Within MS this kind of spasming is typical of lesions in the spinal cord. Did you have a sinal cord MRI?
"Do seizures and MS go hand-in-hand?" True seizures (those that originate in the brain) can be caused by MS - For the kind of "seizure" spoken of by your neurologist see the above answer.
"Can the compartment syndrome cause a seizure of that muscle?" Compartment syndromes cause pressure necrosis of the nerves and muscles by cutting off the vlood supply due to high pressures. When I was primary surgeon (as an intern) rotating through ortho when I opened up the calf of my patient with a traumatic compartment syndrome, the muscle was pale and purple and twitching, but not spasming. True, spasms? I don't really know.
"Can a compartment syndrome cause a positive "babinksi" sign?" - I would say no. The positive Babinski sign is a sign of spinal cord damage/lesion. That sign is an art to elicit and to interpet. If there is pain in the involved limb it can make the test even harder to do.
" If the MRI of the brain shows 3-5 white spots, all tiny, is that proof-positive of MS, even if the other tests (VEP and blood tests) and symptoms are negative?" - No. There is no MRI pattern that is proof positive of MS. Brainstem lesions are more suggestive of MS than brain lesions, because there are fewer diseases that cause lesions there. The VEP is useful only when it is positive. A negative VEP tell you nothing about whether a person has MS. In MS ALL of the blood tests would be expected to be negative. Those tests are to look for diseases OTHER THAN MS.
"Is there a number cut-off in the diagnostic criteria for MS? " - I assume you mean number of lesions. No.
"If you have the feeling the doc is trying to squeeze you into a diagnosis, can you stop the process and go to someone else and be cleared without having to do a spinal tap?" - ABSOLUTELY! You NEVER need to go through a test about which you are uncomfortable! You have the absolute right at any time to leave the care of a physician in whom you have lost confidence - or even just for another opinion or two.
"Can extreme stress (somewhat worse than what the flight crew experienced going into the Hudson, think going into the Hudson in a plane without being able to see), cause white spots in the brain?" - No. Stress does not cause lesions on the brainstem, spine, nor in the brain.
"Are these white spots anything to worry about, especially if you aren't having any other symptoms of MS except the leg issues?" -- In the true absence of any symptoms or neurologic signs of a problem, most neurologists would not worry and just see you periodically to check for the beginning of any symptoms. You do have a +Babinski. Do you have brisk reflexes or any other positives on a thorough, head-to-toe exam? If not, then a "watch and wait" plan makes sense. If I were the neuro, I would make sure that I had obtained MRIs of the entire CNS, the brain, brainstem and the entire spical cord - and I would order them on a 3T machine. Then I would likely watch and wait.
How important is the LP is what you are also asking. Many docs do not use the LP much at all, and it is not required by the diagnostic guidelines.
We have had a few people come through here with lesions, but no symptoms. In most of them the neuro exam uncovered subtle deficits and the symptoms were often not far behind. But, a certain portion of the population has brain lesions and no neuro disease. Few at your age have them. Brainstem lesions are presumed to indicate a problem. So I see why the neuro is concerned, but I don't see the hurry.
I hope this helps. Please remember that my word is NOT gospel of any kind. My answers are based on my reading and my own experience in medicine in general and not on any vast experience in MS.
Quix
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