What are the next steps for a patient who fails the Romberg test?

Failed Romberg Test: Next Steps

A failed (positive) Romberg test indicates proprioceptive pathway dysfunction and requires immediate evaluation with MRI of the cervical and thoracic spine without IV contrast to assess the dorsal columns for compressive myelopathy, B12/copper deficiency, or neurosyphilis, while simultaneously distinguishing sensory ataxia from cerebellar or vestibular causes through targeted physical examination. 1, 2

Understanding What a Positive Romberg Test Means

A positive Romberg test—where the patient becomes significantly more unstable or falls when closing their eyes—specifically indicates sensory ataxia from dorsal column, dorsal root ganglion, or large fiber peripheral nerve dysfunction, NOT cerebellar pathology. 1, 3, 2 This is the critical distinguishing feature: cerebellar ataxia causes instability that persists equally with eyes open or closed (Romberg negative), while sensory ataxia dramatically worsens without visual compensation. 3, 2

Immediate Physical Examination to Localize the Problem

Before ordering imaging, complete these bedside assessments:

• Assess gait pattern with eyes open: Wide-based, lurching gait suggests cerebellar dysfunction; high-stepping gait suggests sensory neuropathy; gait that worsens dramatically with head rotation indicates vestibular rather than proprioceptive dysfunction. 3

• Perform finger-to-nose and heel-to-shin testing: Dysmetria (overshooting/undershooting) that persists with eyes open indicates cerebellar pathology, not sensory ataxia. 3

• Check for truncal instability: Difficulty maintaining seated posture without arm support suggests cerebellar vermian pathology. 3

• Test for dyssynergia and dysdiadochokinesia: Loss of coordinated multi-joint movements and rapid alternating movements indicates cerebellar dysfunction. 3

• Examine eye movements: Nystagmus, ocular dysmetria, or ophthalmoplegia suggest cerebellar or brainstem involvement. 3

Primary Diagnostic Workup for Positive Romberg

Order MRI of cervical and thoracic spine without IV contrast as the first-line imaging study to evaluate the dorsal columns for:

• Compressive myelopathy
• B12/copper deficiency myelopathy
• Tabes dorsalis (neurosyphilis)
• Spinal cord atrophy in degenerative conditions 2

Add IV contrast if you suspect inflammatory, infectious, or neoplastic causes. 2

Obtain laboratory studies simultaneously:

• Vitamin B12 level
• Copper level
• Syphilis serology (RPR/VDRL)
• Complete blood count
• Metabolic panel 2

Arrange electrodiagnostic testing (nerve conduction studies and EMG) to document large fiber sensory neuropathy or dorsal root ganglion involvement, which provides diagnostic confirmation beyond imaging. 2

When to Image the Brain Instead

Order MRI of the head without IV contrast if the examination reveals cerebellar signs (dysmetria, dysdiadochokinesia, nystagmus, dysarthria) that do NOT worsen with eye closure, as this indicates cerebellar ataxia rather than sensory ataxia. 3 Key red flags requiring urgent brain imaging include:

• Headache with truncal ataxia (suggests acute cerebellitis) 3
• Altered consciousness or signs of increased intracranial pressure 3
• Triad of ataxia, areflexia, and ophthalmoplegia (Miller Fisher syndrome) 3
• Torticollis or resistance to neck motion (posterior fossa tumor or craniocervical junction pathology) 3

Treatment Based on Etiology

For treatable causes identified on workup:

• B12 deficiency: Initiate B12 replacement therapy 2
• Copper deficiency: Start copper supplementation 2
• Neurosyphilis (tabes dorsalis): Treat with appropriate antibiotic therapy 2
• Compressive myelopathy: Refer for surgical decompression when indicated 2
• Autoimmune sensory neuropathy: Consider immunotherapy, though evidence is limited 2

Rehabilitation and Safety Measures

Immediately implement fall prevention strategies since sensory ataxia patients rely heavily on vision for balance:

• Emphasize visual compensation techniques—teach patients to actively watch their feet and surroundings 2
• Prescribe walking aids (canes, walkers) to provide additional sensory feedback and stability 2
• Consider ankle-foot orthoses to improve proprioceptive input and gait stability 2
• Ensure adequate lighting in the home environment 2
• Remove tripping hazards and install grab bars 2

Refer to physical therapy for:

• Balance training programs 2
• Postural training to improve trunk control 2
• Task-oriented upper limb training for fine motor control 2

Critical Pitfalls to Avoid

• Do not assume cerebellar pathology from a positive Romberg test—this is sensory ataxia by definition, and the workup focuses on spinal cord and peripheral nerve pathology, not the cerebellum. 1, 3, 2

• Do not skip the treatable causes workup—always investigate B12, copper, neurosyphilis, and compression before concluding the condition is idiopathic. 2

• Do not confuse vestibular dysfunction with sensory ataxia—vestibular patients have vertigo and gait that worsens with head rotation, not simply eye closure. 3

• Ensure test safety—position yourself close enough to catch the patient during testing, particularly when eyes are closed, and avoid testing in patients with severe cervical stenosis or vertebrobasilar insufficiency where rapid position changes pose risk. 1