From the Guidelines
The Upper Motor Neuron (UMN) spine lesion would most likely be located in the cervical spine, specifically between C5 and C7, given the patient's symptoms of heavy leg feeling, intentional tremor of hands, weakness of fingers, and numbness and sharp pain in the right hand and forearm upon ulnar flossing exercise.
Key Points
- The patient's symptoms, such as positive Babinski sign, heavy leg feeling, and intentional tremor of hands, suggest an upper motor neuron lesion 1.
- The absence of lesions in the brain, C1, C2, C3, or C4, and the presence of symptoms affecting the lower limbs and hands, point towards a cervical spine lesion 1.
- The patient's age and family history of Multiple Sclerosis (MS) increase the likelihood of an MS-related lesion 1.
- MRI of the cervical spine is the most appropriate imaging modality to evaluate the spinal cord and surrounding structures in patients with suspected demyelinating disease, such as MS 1.
- The MAGNIMS criteria can be used to diagnose MS, which includes the presence of lesions in the spinal cord, particularly in the cervical region 1.
From the Research
Clinical Presentation
The patient presents with a range of symptoms, including:
- Positive Babinski sign, indicating upper motor neuron (UMN) dysfunction 2
- Heavy leg feeling, intentional tremor of hands, weakness of fingers, and full body muscle tics
- Preserved vision
- Numbness and sharp pain in the right hand and forearm upon ulnar flossing exercise
Diagnostic Considerations
Given the patient's symptoms and family history of Multiple Sclerosis (MS), a spinal lesion is suspected. However, the absence of lesions in the brain, C1, C2, C3, or C4 suggests that the lesion may be located in the lower cervical or thoracic spine.
Relevant Studies
Studies have shown that UMN lesions can cause a range of symptoms, including intention tremor 3 and spasticity 4. Transcranial magnetic stimulation (TMS) can be used to assess UMN damage and differentiate between neurodegenerative disorders such as amyotrophic lateral sclerosis (ALS) and multiple system atrophy (MSA) 5.
Possible Location of the Lesion
Based on the patient's symptoms and the absence of lesions in the upper cervical spine, the lesion is likely located in the lower cervical or thoracic spine, possibly at the level of C5 or below. This is consistent with the patient's symptoms of numbness and sharp pain in the right hand and forearm upon ulnar flossing exercise, which suggests involvement of the C8 or T1 nerve roots.
Differential Diagnosis
The patient's symptoms and family history of MS suggest that the lesion may be related to MS or another demyelinating disorder. However, the presence of a spinal lesion in a patient with a family history of MS does not necessarily confirm the diagnosis of MS, as other conditions such as Fabry disease can also cause spinal lesions 6. Further diagnostic testing, including MRI and laboratory studies, is needed to confirm the diagnosis and rule out other potential causes of the patient's symptoms.