A Case of Nerves

1. After several years of progressively worsening symptoms, starting with intermittent muscular rigidity and spasms in the lower back, this patient now has stiff leg muscles (more pronounced on the right side). On exam, she demonstrates a slow, stiff manner of walking and lordosis of the lower spine.

Diagnosis: Moersch-Woltman syndrome, or stiff person syndrome, is a rare acquired neurologic disorder, affecting both men and women of any age; most, however, are women. Thought to be an autoimmune disorder, this syndrome may localized to one area of the body or may be widespread, and rapidly progressive, including the body, brain stem, and spinal cord. If untreated, the patient may have difficulty walking and performing activities of daily living.

For more information, see “Stiff Person Syndrome.”

For the next photograph, proceed to the next page >>

2. This patient lost control of her eye and eyelid rather suddenly and then noticed difficulty swallowing and slurred speech. She is now experiencing limb weakness that worsens as the day progresses.

Diagnosis: Myasthenia gravis is a chronic autoimmune disease characterized by varying degrees of weakness of the skeletal muscles of the body. Muscles that control eye and eyelid movement, facial expression, chewing, talking, and swallowing are often, but not always, involved in the disorder. The muscles that control breathing and neck and limb movements may also be affected.

For more information, see “Test Accurately Diagnoses Myasthenia Gravis.” Neurology Reviews. 2016;24(3):36.

For the next photograph, proceed to the next page >>

3. After a night out on the town, this patient is concerned that something is wrong, and it’s not the splitting headache: He is unable to extend his right wrist, thumb, or fingers in the pronated position. Furthermore, the radial and dorsal skin is numb. During the history, he reports that he fell asleep sitting upright with his arm over the back of a chair.

Diagnosis: Radial neuropathy, or Saturday night palsy, is typically produced by direct, prolonged pressure on the radial nerve. The nerve is especially susceptible as it spirals around the midportion of the humerus, in this case by allowing the hard edge of a chair back to compress it all night long. Although alcohol and drugs are usually implicated, radial palsy can also result from fracturing the humerus, leaning on crutches, or from long-term constriction of the wrist (tight watch or bracelet).

For more information, see “9.19 Radial Neuropathy (Saturday Night Palsy).”

For the next photograph, proceed to the next page >>

4. The patient reports spontaneous severe pain near his right shoulder, unrelated to any trauma. Two weeks later, the shoulder protrudes in a winglike position on the upper back, made more apparent when the same side arm pushes against resistance. He has limited ability to lift that arm above his head.

Diagnosis: Winged scapula injury is due to dysfunction of the anterior serratus muscle, which is supplied by the injury-prone long thoracic nerve.

Damage can be caused by a contusion or blunt trauma of the shoulder, traction of the neck, and sometimes a viral illness. Paralysis of the serratus anterior muscle has been well documented among athletes and laborers. To identify an injury, the patient stands facing a wall from about two feet away and then pushes against the wall with flat palms at waist level. Conservative treatment is often recommended; if after 6-24 months if there is no recovery, patients become candidates for corrective surgery.

For more information, see “Scapular winging: anatomical review, diagnosis, and treatments.” Curr Rev Musculoskelet Med. 2008;1(1):1-11.

Related article
For more on peripheral neuropathies, see “An easy approach to evaluating peripheral neuropathy.” J Fam Pract. 2006 October;55(10):853-861.

Photographs courtesy of Ashley Owens and Alexander Orban. They are included for illustration only and do not represent actual cases.

1. After several years of progressively worsening symptoms, starting with intermittent muscular rigidity and spasms in the lower back, this patient now has stiff leg muscles (more pronounced on the right side). On exam, she demonstrates a slow, stiff manner of walking and lordosis of the lower spine.

Diagnosis: Moersch-Woltman syndrome, or stiff person syndrome, is a rare acquired neurologic disorder, affecting both men and women of any age; most, however, are women. Thought to be an autoimmune disorder, this syndrome may localized to one area of the body or may be widespread, and rapidly progressive, including the body, brain stem, and spinal cord. If untreated, the patient may have difficulty walking and performing activities of daily living.

For more information, see “Stiff Person Syndrome.”

For the next photograph, proceed to the next page >>

2. This patient lost control of her eye and eyelid rather suddenly and then noticed difficulty swallowing and slurred speech. She is now experiencing limb weakness that worsens as the day progresses.

Diagnosis: Myasthenia gravis is a chronic autoimmune disease characterized by varying degrees of weakness of the skeletal muscles of the body. Muscles that control eye and eyelid movement, facial expression, chewing, talking, and swallowing are often, but not always, involved in the disorder. The muscles that control breathing and neck and limb movements may also be affected.

For more information, see “Test Accurately Diagnoses Myasthenia Gravis.” Neurology Reviews. 2016;24(3):36.

For the next photograph, proceed to the next page >>

3. After a night out on the town, this patient is concerned that something is wrong, and it’s not the splitting headache: He is unable to extend his right wrist, thumb, or fingers in the pronated position. Furthermore, the radial and dorsal skin is numb. During the history, he reports that he fell asleep sitting upright with his arm over the back of a chair.

Diagnosis: Radial neuropathy, or Saturday night palsy, is typically produced by direct, prolonged pressure on the radial nerve. The nerve is especially susceptible as it spirals around the midportion of the humerus, in this case by allowing the hard edge of a chair back to compress it all night long. Although alcohol and drugs are usually implicated, radial palsy can also result from fracturing the humerus, leaning on crutches, or from long-term constriction of the wrist (tight watch or bracelet).

For more information, see “9.19 Radial Neuropathy (Saturday Night Palsy).”

For the next photograph, proceed to the next page >>

4. The patient reports spontaneous severe pain near his right shoulder, unrelated to any trauma. Two weeks later, the shoulder protrudes in a winglike position on the upper back, made more apparent when the same side arm pushes against resistance. He has limited ability to lift that arm above his head.

Diagnosis: Winged scapula injury is due to dysfunction of the anterior serratus muscle, which is supplied by the injury-prone long thoracic nerve.

Damage can be caused by a contusion or blunt trauma of the shoulder, traction of the neck, and sometimes a viral illness. Paralysis of the serratus anterior muscle has been well documented among athletes and laborers. To identify an injury, the patient stands facing a wall from about two feet away and then pushes against the wall with flat palms at waist level. Conservative treatment is often recommended; if after 6-24 months if there is no recovery, patients become candidates for corrective surgery.

For more information, see “Scapular winging: anatomical review, diagnosis, and treatments.” Curr Rev Musculoskelet Med. 2008;1(1):1-11.

Related article
For more on peripheral neuropathies, see “An easy approach to evaluating peripheral neuropathy.” J Fam Pract. 2006 October;55(10):853-861.

Photographs courtesy of Ashley Owens and Alexander Orban. They are included for illustration only and do not represent actual cases.

1. After several years of progressively worsening symptoms, starting with intermittent muscular rigidity and spasms in the lower back, this patient now has stiff leg muscles (more pronounced on the right side). On exam, she demonstrates a slow, stiff manner of walking and lordosis of the lower spine.

Diagnosis: Moersch-Woltman syndrome, or stiff person syndrome, is a rare acquired neurologic disorder, affecting both men and women of any age; most, however, are women. Thought to be an autoimmune disorder, this syndrome may localized to one area of the body or may be widespread, and rapidly progressive, including the body, brain stem, and spinal cord. If untreated, the patient may have difficulty walking and performing activities of daily living.

For more information, see “Stiff Person Syndrome.”

For the next photograph, proceed to the next page >>

2. This patient lost control of her eye and eyelid rather suddenly and then noticed difficulty swallowing and slurred speech. She is now experiencing limb weakness that worsens as the day progresses.

Diagnosis: Myasthenia gravis is a chronic autoimmune disease characterized by varying degrees of weakness of the skeletal muscles of the body. Muscles that control eye and eyelid movement, facial expression, chewing, talking, and swallowing are often, but not always, involved in the disorder. The muscles that control breathing and neck and limb movements may also be affected.

For more information, see “Test Accurately Diagnoses Myasthenia Gravis.” Neurology Reviews. 2016;24(3):36.

For the next photograph, proceed to the next page >>

3. After a night out on the town, this patient is concerned that something is wrong, and it’s not the splitting headache: He is unable to extend his right wrist, thumb, or fingers in the pronated position. Furthermore, the radial and dorsal skin is numb. During the history, he reports that he fell asleep sitting upright with his arm over the back of a chair.

Diagnosis: Radial neuropathy, or Saturday night palsy, is typically produced by direct, prolonged pressure on the radial nerve. The nerve is especially susceptible as it spirals around the midportion of the humerus, in this case by allowing the hard edge of a chair back to compress it all night long. Although alcohol and drugs are usually implicated, radial palsy can also result from fracturing the humerus, leaning on crutches, or from long-term constriction of the wrist (tight watch or bracelet).

For more information, see “9.19 Radial Neuropathy (Saturday Night Palsy).”

For the next photograph, proceed to the next page >>

4. The patient reports spontaneous severe pain near his right shoulder, unrelated to any trauma. Two weeks later, the shoulder protrudes in a winglike position on the upper back, made more apparent when the same side arm pushes against resistance. He has limited ability to lift that arm above his head.

Diagnosis: Winged scapula injury is due to dysfunction of the anterior serratus muscle, which is supplied by the injury-prone long thoracic nerve.

Damage can be caused by a contusion or blunt trauma of the shoulder, traction of the neck, and sometimes a viral illness. Paralysis of the serratus anterior muscle has been well documented among athletes and laborers. To identify an injury, the patient stands facing a wall from about two feet away and then pushes against the wall with flat palms at waist level. Conservative treatment is often recommended; if after 6-24 months if there is no recovery, patients become candidates for corrective surgery.

For more information, see “Scapular winging: anatomical review, diagnosis, and treatments.” Curr Rev Musculoskelet Med. 2008;1(1):1-11.

Related article
For more on peripheral neuropathies, see “An easy approach to evaluating peripheral neuropathy.” J Fam Pract. 2006 October;55(10):853-861.

Photographs courtesy of Ashley Owens and Alexander Orban. They are included for illustration only and do not represent actual cases.