Evaluation of Recurrent Tripping Without Other Symptoms
Order a comprehensive neurological examination focusing on gait assessment, lower extremity motor strength, proprioception testing, and cerebellar function, followed by MRI of the brain and cervical/thoracic spine without IV contrast if any abnormalities are detected.
Initial Clinical Assessment
The patient's isolated symptom of recurrent tripping suggests either sensory ataxia (proprioceptive dysfunction) or cerebellar ataxia, requiring systematic evaluation to differentiate the underlying cause 1.
Essential Neurological Examination Components
Perform a focused neurological examination that includes:
- Gait assessment: Observe for wide-based gait (cerebellar), steppage gait (foot drop), or sensory ataxia patterns 2
- Lower extremity motor testing: Assess for weakness, particularly dorsiflexion strength that could cause foot drop 2
- Proprioception testing: Evaluate joint position sense and vibration sense in the lower extremities 2
- Cerebellar function: Test finger-nose coordination, rapid alternating movements, and heel-to-shin testing 2
- Tone assessment: Check for spasticity or rigidity in arms and legs 2
- Deep tendon reflexes: Evaluate all five major tendon reflexes and plantar responses 2
- Romberg test: Assess for sensory ataxia versus cerebellar dysfunction 1
Imaging Decision Algorithm
If Cerebellar Signs Are Present (ataxia, dysmetria, intention tremor):
Order MRI head without IV contrast as the primary imaging modality 1. This is the most appropriate test for evaluating cerebellar atrophy, posterior fossa lesions, or other cerebellar pathology 1. Consider MRI head without and with IV contrast if there is concern for demyelinating disease or mass lesions 1.
If Sensory/Proprioceptive Deficits Are Present (impaired position sense, vibration loss):
Order MRI cervical and thoracic spine without IV contrast 1. This evaluates for spinal cord pathology affecting the dorsal columns, such as cervical stenosis, myelopathy, or spinal cord atrophy 1. MRI cervical and thoracic spine without and with IV contrast may be appropriate if inflammatory or demyelinating conditions are suspected 1.
If Neurological Examination Is Normal:
In patients with normal neurological examination but persistent tripping, imaging has low diagnostic yield 1. However, if the patient has vascular risk factors (older age, hypertension, diabetes), consider MRI head without IV contrast to evaluate for subtle posterior circulation infarcts or small vessel disease 1.
Common Pitfalls to Avoid
- Do not order imaging without performing a thorough neurological examination first - the examination findings guide appropriate imaging selection 1
- Do not assume a benign cause - isolated gait disturbance can be the presenting symptom of serious neurological conditions including spinal cord compression, cerebellar degeneration, or posterior circulation stroke 1
- Do not overlook medication review - certain medications can cause ataxia or proprioceptive dysfunction 3
- Do not dismiss the complaint - recurrent falls significantly increase morbidity risk, particularly in older adults 4
Additional Considerations
If initial neurological examination and imaging are unrevealing but symptoms persist, consider:
- Vestibular function testing if there is any component of imbalance or disequilibrium 4
- Electromyography and nerve conduction studies if peripheral neuropathy is suspected based on examination findings 5
- Vitamin B12, folate, and thyroid function tests if metabolic causes of proprioceptive dysfunction are considered 1
The key is matching the imaging modality to the examination findings: cerebellar signs warrant brain MRI, while sensory/proprioceptive deficits warrant spine MRI 1.