r@
CLINICALNOTES
Evaluatlon of Neurologl< Deficit without Apparent (ause:
The lmpo.tance of a Multldisdplinary Approach
BadeyE. smdh,MDIj turphr Rymine.MDI;chlrauk 9NaroqMD], h
loieph I rG., PhD'?j
lohn R*ri4 MD'];ramerNlmp, MD'' rodd Alben,
'iDepatued or odlropaedt sdgery,
ph
lefieron unreEity tlospiGr, adep
s..rsreund/ob,.drrc: A pdied p
olqaii. dnoder, :nd d thRjunc'ure
idsrry ns my psy.rr*ft
'r
srds b
aPproF de diagnd c nudis cn co
(neurorosy,
psy.lriat'y,sochlwo,k, m€dkar5pech5b) sry lu thc ev.Luation
ot avpi.cr paiary55
may
tphp' .otd M.d, 2oo7i3o:5or51,
'
h Fnsltivi9 lor the
bF.riE . nicr or
pbri t frr : oie rdr $e d: u4idi of .ery 6 $rie
tomogaPhy(cr) rmashg hasa cP
dbqnosis
orlradurenthe.efl.arspne(r) hthe.ae
o f b d g a |a wt r* t e m' y p m|y s s i
riown hjuryb (herpie a &mpde
of the
'ratioi
(MRr)or the bain, .€ ti, md thon.oumbaispiial
rhe hilrnal ot spln'r <ord M€di'ine
(nil.oti.5 iee*hq, $eknq ho6iq, &odiD.e or
'o4
dO lhoud be appEFd. rr sympbm5m nientonrrv
i8m or nlury
''d
lbjedve .ompranb qens. y do nd .oneit. w(h
u'y motorand/o,froryilndiof
su
As outrhed,nuhplc p5y.hi3!i..ond(otr Gdi'er
and mrhqsiiq)
Gn prcfnt wnh neroogc d-4i.r'
€ snr PcEon(4)'
, d ti.art n€drcroer. .ompL n6 ( e, paE y:L). . it,
(iorma rerlexes,
Gb sennlon and rore, bdbo.,vs
r
dois rcrd) 5hodd rie rhe hdq or jurpoon
'or
m*iq.menl
dnorde,(4).h.od
or somatzarron
ind eiPqei.er
in hii/her5ynproms
dljords b€rieves
ind an MR, myeoqn
somdosrory.eloN.d porcd rr {s54t :nd mobr
soled potontiat(MtPt evarua'e(h.deo(y di aisory
diitbe d: liinndoni (r2)
cr (sPE.l ri
p€iod. pmrrs5 (r 61 3t Auioimmu
(4) ro, the diriss(i
daqno< ro. tlrc Badtof
rudcar
moiornimlri. v! humicrd ar(re) h?veEponed$d
or
b ya q e n e r a!medra|.o|drion,thcnb . |o n d ] rro t ih e
sprndr.irnc, c.nrcrren
rhe spinil hju, c c.nt€. (5rOrcn wasdcrr b.d by
a d i t y lheev doldec e d e d c a u d d
es Eldi or.oNssioi dnods
Yuef etar0a
'o.lhe
hysedarsymptomi
d rorlowup vst (re).
tuid o n a M
r Rr(rMR) idedrr$E qd oitrrb ii
(20)wth.enah'MRr maehefque
M{+a
d a {21) d$qbed
a fMR nudy oD a
d mt thcrcw*
thc'dvi9 in thor rcsions
slsssr
paialyll,theall{Ed|imbwi|
m6dc.odradon oi the hamndo$ (r4
(2r) Mr5h . rc r. l
(2r),so for€ thatdE ad$fbq€r or
(Prr) rude the abf,.e o'
Add tbm ,l M R |sdaymdeU
pd:ystwl|typk.y
atcmptinsto5t'.elcxivc|yldngt
(:22,23)rhir 5hondnq
(uiinvdred) rinb
-
lbtutr.ios (urca 4d).odri.r, ir 5hyporhe5=dtbd
(7,3,r0,rr,8,25), ther i.idsc
L trbr€y
Bre (4)
rpiial .od hjury @ er dd
nldier Gny, cr, md MR) dd not d.ntiry roy
pitienlt ows e*remV wearn€$wth no apprcrt
abfd rr*ion
and moior<rvi!
b
rmstured b a spm cdd hlury ce
spiid .od iiiu,y eudier (NAsct pm'd.dl
s s € P d ln g md f Mc mi|y jijb e p e rlq me d ' w h l . h
rcpon€d mbilrry to nove hB
of my obicdrc frndnssb
uPptr enremry nrcnglh d 5/5
lrmed,i(wd|heophionoilhene
i iopsod/quadi..ptt b i ir
ionguts-rocncm6 muicc s.oup5had 0/5 nrcnsrh.
vssar,
bmy niudeswse dert
'ie
voriron,?nd bu bo.av€,nosus
reirex.rhe bi.eptrtepr
mudc nrckh erlercs wsc 2 /4 b aten r, and h s
pdelhr^.hirl8 rc,lexd wse r'r1 b kd y Babdi
Hofimmn,sjlrnswgereqa''€b]laknly
Becreo' rhe m<hansm of njL,ryin,r abFrce or
or.dcdemps?|ywthmdtra
dsnit ns a sps.i'i. lbnom? iry
moior.onexGpp,opturarrerorhnri{cd imb)whei
ot konriicnt w th
apathy ol hteno; w€ hypoth€Qed thar dre preien.e or
oj!ry Prcb(o Pbn
frofy
b5L rhe Pdiert wr
$e *udy (fieurc5r dod 2) rhe pdied! asibron
tr
u
si
m'ifft,n,iffm4,1
r!
irl!-
(26,27).
wheths the k.r ot moto
thepl€Nwihp*:|yljolnoapp}e
sh birnarco(
c ier ns behdor Gb
wd : preniptoi ior iar.dl. p;d nedrddn) rhe
rh. ,.um.r of 5PrnarcordMedkhe
e d rhevo* up oi,ny pdcnrwirh a!pGlpaftrysk
* ;' ,f 1,
';,-\
-|
I rr H rr ur ll!_!j_tr_l! tt r--5
t.omprB o i (m. g e . o u mrc ro )
-Ll
:)
n (ima g e . o u o n1s 5 ). n d rM R rm a q s
di,th5l!rtM,
draensfc etrod foturd on lr.nurt nq my psydrkr.
reFded hiury (h rhs aic , Pcde
mdbrvehr4, any pftrt presedoe wrh rn acdc o'
0aut5ympiomthdwg€nim'bmy'a'nddby
thcpdcnt. n rcto5pc.l d,r prenr preaNeddaqio!
on Grypta rde
cqredoewrharepdded haundc nju,yoi.onsids
abe rdr.O
hr pl3yi
may be psy.hoqea. n
'hat
dertt psy.hoeen. piarri wse od pedqmd d
niury md r crfofr had ben di<kd
of Pfatrt
:oiq
b a mqe rhdmlqh
sc, 1.rc$ LM, MuphyMA A
.ompdd booqBphyd o adi!rci6r cryr, fhe
, B4 Pc,Hah6sr aak ralnq{ d,rhd.od f!ry
.ut t@t oPtbft N&at. 2ro02 ! 7 5r1
r Miq€naMA,rshr 1, Robba. erulon d sae hiqry
wrh psydo$ri
r4
€pqrry. / P4h,!a 4s. ree6,11rr5
3. kbion El,wnam5rR, 5dh! 6
pry.turt d$de, Godvediondndds) wn d aqnd€d
a porp(
ro 0doMN, uqren c lPa.ro4rtprafi
\ye *!d, us6n bes1 2oaa)162
56i, 56i4.
qdutoi
ior tn€rtd p'ar'
t BpaM
pPofruatylolorm
rph! ,oe2erqc
R4 le6s:e:e13
r5HgltjR].on€tronndqFE|ysddLqerJad'Mfd/
An I EdetsMed.
7.
a4f5
p{it5L qseunidsbrr
13 obq Kp rtrebxr Fidn '4o.,21f,1
20IurerR'Hosem
th€ loumll or tpr..r aod M.dkrn€
ARe$cE]ofPBo,|dbn(
dibden
r prclpeii4
@iftr
srcup n!dy. / N4rcr
|942'caqMd1992'56j59
oi
o*!n Ms, (eHaPl. ebickl ch6rdftEdrid
qsdt padtds rrcm hyreidr FBTFL, !f<t on !s
.onlshndld€i,o9N.u4'dqfom@ladPlr
eacr DN, s€ibr rl r,bd c, iudey M .onw6oo
hylda:kso$lremiunilmima9h9']N&4*h"lry