GAIT DISTURBANCES

GAIT DISTURBANCES: Excerpt from Differential Diagnosis in Primary Care

The anatomic location of the lesion in a gait disturbance depends on the type of disturbance.

GAIT DISTURBANCES

1. Spastic gait. In this type of lesion, both feet shuffle along the floor in short steps and the legs are close together moving in a scissorslike fashion. Spastic gait is caused by lesions of both pyramidal tracts anywhere from the lower spinal cord to the brainstem and brain. The principal disorders are the following:
   1. In the cord. Multiple sclerosis, amyotrophic lateral sclerosis, spinal cord tumors, syringomyelia, and cervical trauma or spondylosis.
   2. In the brainstem. Tumors, basilar artery thrombosis, multiple sclerosis, platybasia, and progressive lenticular degeneration.
   3. In the brain. Cerebral arteriosclerosis, cerebral palsy, general paresis, and senile and presenile dementia.
2. Hemiplegic gait. One foot is dragged above the floor, swinging out in a semicircular fashion. This is due to involvement of only one pyramidal tract, usually in the brain. Cerebral hemorrhage, thrombosis, emboli, and space-occupying lesions may be the culprits. Multiple sclerosis, early cervical cord tumor, or disc may do the same.
3. Steppage gait. Because of the weakness of dorsiflexion of both feet the patient has to lift the foot high to avoid tripping. The lesion is a diffuse peripheral neuropathy that may be from lead intoxication, alcoholism, diabetes, porphyria, perineal muscular atrophy, or a cauda equina tumor. There are many other causes of peripheral neuropathy discussed on page 541.
4. Limping gait. Pain in one lower extremity due to bone disease, sciatica, hip disease, knee joint disease, and ankle and foot disorders of all types may cause favoring of the painful limb and quickening of the stride on that side so the victim can get back on the healthy limb. Osteoarthritis of the hip or knee, a herniated disc, an osteoarthritic spur of the heel, a sprained ankle, and fracture of any of the bones of the limb are typical conditions causing this type of gait.
5. Ataxic gait. The gait is wide-based, clumsy, and staggering. An ataxic gait may be sensory or cerebellar. Sensory ataxia is due to a lesion of the dorsal columns, such as tabes dorsalis, pernicious anemia, or a spinal cord tumor. In sensory ataxia, the patient walks carefully with his eyes fixed on the ground. Cerebellar ataxia is due to involvement of the spinocerebellar tracts and cerebellum. This occurs in hereditary cerebellar ataxia, Friedreich ataxia, cerebellar tumors, multiple sclerosis, and alcoholic cerebellar atrophy. In a cerebellar ataxia, the patient reels about when walking and it is not much more difficult to walk with the eyes closed. Multiple sclerosis and syringomyelia may involve the dorsal columns, pyramidal and spinocerebellar tracts, or cerebellum, producing a mixed spastic–ataxic gait.
6. Muscular dystrophy gait. This is wide-based with a pelvic tilt forward as if the patient is trying to “show off,” but the feet are lifted from the ground with difficulty and there is waddling or rolling from side to side.
7. Extrapyramidal disease gait. The gait is short-stepped, spastic, and the feet shuffle along the ground. The patient may tilt forward with trunk and head bent toward the ground, causing acceleration (propulsion); at times the reverse may occur (retropulsion). In Huntington chorea, the gait is clownish and grotesque, as if the patient were drunk but playing games.

Approach to the Diagnosis

The workup depends on the presence or absence of other neurologic signs. If a peripheral nerve lesion is suspected, a workup for diabetes and a careful history for alcoholism and porphyria are expected. A suspected spinal cord lesion requires x-rays of the spinal column, spinal tap, Schilling test, and possibly a myelogram or MRI. When the lesion is believed to be in the brain or brainstem, an MRI or CT scan are almost axiomatic before a spinal tap or other radiocontrast studies are considered. A neurologist or neurosurgeon can best decide how the workup should be conducted.

Other Useful Tests

1. CBC (pernicious anemia)
2. Sedimentation rate (epidural abscess, collagen disease)
3. FTA-ABS test (neurosyphilis)
4. Tuberculin test (tuberculosis of the spinal column)
5. Chemistry panel (muscle disease, cirrhosis)
6. Serum protein electrophoresis (multiple myeloma)
7. Blood lead level (lead neuropathy)
8. ANA analysis (collagen disease)
9. RA test (rheumatoid arthritis)
10. Serum B12 and folate levels (pernicious anemia)
11. Urine porphobilinogen (porphyria)
12. Twenty-four–hour urine for creatinine and creatine (muscular dystrophy)
13. Muscle biopsy (muscular dystrophy, collagen disease)

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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