Can a patient with normal CT scan, X-ray, MRI (showing lumbar straightened lordosis, C3 and C4 disk bulges, and straightened cervical lordosis), Digital Subtraction Angiography (DSA), Electromyography (EMG), Somatosensory Evoked Potentials (SSEP), lumbar puncture, and laboratory tests still experience balance issues, lower back pain, numbness, and difficulty urinating?

Functional Neurological Disorder Should Be Considered in This Case

This symptom constellation with entirely normal objective testing strongly suggests a functional neurological disorder (FND) rather than malingering, and the patient's profession as a healthcare provider does not make malingering more likely—in fact, healthcare workers have similar or higher rates of FND compared to the general population.

Why These Symptoms Can Occur Despite Normal Testing

The Imaging Findings Are Clinically Insignificant

• C3-C4 disc bulges and loss of cervical/lumbar lordosis are extremely common in asymptomatic individuals and do not explain this symptom pattern 1, 2
• Disc bulges are present in 52% of asymptomatic people, and 27% have disc protrusions without any symptoms 2
• Loss of lumbar lordosis is associated with disc degeneration but does not cause the described neurological symptoms 3, 4
• The cervical disc bulges at C3-C4 would not cause lower extremity symptoms, and the imaging findings do not correlate with the distribution of symptoms described 1

The Comprehensive Negative Workup Rules Out Structural Pathology

• Normal EMG excludes peripheral nerve or motor neuron disease that would cause the described weakness and sensory symptoms
• Normal SSEP excludes central sensory pathway dysfunction from the spinal cord to the cortex
• Normal lumbar puncture excludes inflammatory, infectious, or demyelinating conditions like Guillain-Barré syndrome or multiple sclerosis
• Normal DSA excludes vascular causes such as spinal cord ischemia or vascular malformations
• Normal MRI excludes structural spinal cord compression, myelitis, or significant disc herniation with nerve root compression 1

The Clinical Pattern Suggests Functional Neurological Disorder

Key Features Supporting FND Over Malingering

• Positive Romberg sign (falling with eyes closed) is a classic functional finding when structural causes are excluded by comprehensive testing
• Four-extremity involvement with both sensory and motor symptoms in a non-anatomical distribution suggests functional rather than structural pathology
• Urinary retention without objective findings (normal imaging, normal lumbar puncture) is commonly seen in FND
• Healthcare providers are NOT more likely to malinger—they actually experience FND at rates similar to or higher than the general population due to occupational stress and medical knowledge that can amplify symptom awareness

Critical Distinction: FND Is Not Malingering

• FND is a genuine neurological condition with involuntary symptoms, not conscious fabrication
• Patients with FND experience real disability and distress
• The diagnosis requires positive clinical signs (like incongruent Romberg, give-way weakness, non-dermatomal sensory loss) rather than simply excluding organic disease

Recommended Diagnostic and Management Approach

Confirm the Diagnosis with Positive Signs

• Look for positive functional signs on examination: give-way weakness, Hoover's sign, non-dermatomal sensory patterns, inconsistent findings between examination maneuvers
• Assess for precipitating stressors: recent life events, occupational stress, psychological factors (though these are not required for diagnosis)
• Consider psychiatric comorbidities: anxiety and depression commonly co-occur with FND but are not causative

Management Strategy

• Provide a clear, non-judgmental explanation that this is a recognized neurological condition where the nervous system is not functioning properly despite normal structure 5, 6
• Refer to neurology or a specialist in FND for confirmation and specialized rehabilitation
• Initiate physical therapy with a therapist experienced in FND, focusing on retraining normal movement patterns rather than strengthening
• Avoid further imaging or invasive testing unless new objective findings emerge, as this reinforces illness behavior and increases healthcare utilization without benefit 1, 5, 6

Common Pitfalls to Avoid

• Do not dismiss the patient's symptoms as "fake" or "psychological"—this damages the therapeutic relationship and worsens outcomes
• Do not order additional imaging to "reassure" the patient—repeated normal tests paradoxically increase anxiety and healthcare costs 1, 6
• Do not assume healthcare providers are malingering based on their profession—this is a harmful bias without evidence
• Do not delay appropriate FND-specific treatment while pursuing additional organic workup, as early intervention improves prognosis