Foot drop following brain tumors: case reports

Prognostic indicators of surgical outcome in painful foot drop: a systematic review and meta-analysis

PURPOSE

Foot drop is a relatively uncommon presentation of lumbar degenerative disease and there is currently a paucity of evidence on management and outcomes which is reflective of the lack of standardised treatment provided to patients. The purpose of this systematic review and meta-analysis is to determine the effectiveness of surgical management and the factors that predict surgical outcome.

METHODS

A systematic database search of Cochrane Library, Ovid Medline, Pubmed, Embase and Google Scholar was undertaken from inception through August 2018. Only studies reporting on surgical outcome in adult patients who had a painful foot drop and underwent decompression were included. Case reports and studies with surgical fixation were excluded. Study quality was assessed using the Newcastle-Ottawa Scale. Data were pooled using a random-effects model.

RESULTS

797 studies were screened and 9 observational studies met the inclusion criteria. This resulted in a total of 431 patients who underwent decompression for foot drop. Pooled rates of outcome for improvement in foot drop MRC grade were 84.5% (range 67.9-96%). Sub-group meta-analyses of studies revealed a statistically significant association between duration of foot drop (pooled 4.95 [95% CI 1.13-21.74]), severity of preoperative weakness (pooled 0.38 [95% CI 0.15-0.93]) on post-operative outcome and age (pooled 6.28 [1.33-29.72]).

CONCLUSION

This is the first systematic review and meta-analysis to explore the outcome and prognostic indicators of lumbar decompression for foot drop. Findings indicate that age, duration of foot drop weakness and MRC grade of foot drop prior to intervention were strong predictors of surgical outcome.

Drop foot due to lumbar degenerative disease: Painless drop foot is difficult to recover

OBJECTIVE

To evaluate the improvement of drop foot following lumbar decompression surgery and determine the prognostic factors that might influence the recovery of drop foot.

SUMMARY AND BACKGROUND DATE

Drop foot is a common but serious problem that can lead to deteriorate patient's daily activities. There are numerous studied regarding the prognostic factors for the recovery of drop foot. However a few reports have been described the pathophysiological etiology of not only drop foot but also Trendelenburg's sign due to the L5 nerve root palsy. Therefore, there is a possibility drop foot caused by peroneal nerve palsy is included. In addition, none have evaluated the presence or absence of radicular leg pain with drop foot patients. The purpose of this study was to evaluate the improvement of paretic leg muscles and determine the prognostic factors that might influence the recovery of drop foot.

METHODS

Fifty-five drop foot patients were included in the study. Prognostic factors were retrospectively studied.Patients were assessed in terms of 10 items: 1) age, 2) sex, 3) diagnosis (LDH or LSS), 4) muscle strength of tibialis anterior, 5) muscle strength of extensor halluces longus, 6) muscle strength of gluteus medius, 7) presence or absence of radicular leg pain, 8) duration before surgery, 9) surgical treatment (spinal fusion or not), 10) anamnesis of diabetes mellitus.

RESULTS

Thirty-two (58.2%) of 55 patients recovered from their drop foot (manual muscle test of tibialis anterior ≥ 4 at final follow-up), while 23 (41.8%) did not (manual muscle test of tibialis anterior ≤ 3 at final follow-up). The strength of all muscles that were innervated and controlled by the L5 nerve root had recovered at the final follow-up when evaluated as averages. Multivariate logistic regression analysis revealed significant differences in terms of 2 items: "duration before surgery" and "presence or absence of radicular leg pain".

CONCLUSIONS

"Duration before surgery" and "presence or absence of radicular leg pain" are important to predict the recovery of drop foot. Painless drop foot patients with lumbar degenerative disease are difficult to recover their paralysis.

A rare case of parasagittal meningioma causing isolated foot drop: case report and review of the literature

Foot drop represents a very common reason for a neurologist referral and is often first seen in emergency departments or by a general practitioner. This condition is defined as weakness of ankle dorsiflexion (mainly through tibialis anterior muscle weakness). The most common causes include lower motor neuron lesion, with L4-L5 radiculopathy and peroneal neuropathy being the most frequent ones. Classical diagnostic pathway includes a thorough medical history, detailed neurological examination, radiological studies (MRI of the lumbosacral spine), EMG and nerve conduction studies, and a battery of laboratory tests. The absence of abnormal radiological and neurophysiological findings when searching for the most common causes of foot drop, should raise a red flag and broaden the diagnostic yield for central nervous system pathology (upper motor neuron, UMN) as a possible cause of foot drop. Central causes of isolated foot drop are very rare, with less than 20 cases reported in literature so far, and seven of them being a meningioma. We present a case of a 79-year-old female patient with an isolated foot drop (with no UMN signs on the initial examination) and parasagittal meningioma. Central causes of foot drop should be suspected when foot drop is associated with UMN signs on examination (hyperreflexia of the patellar or ankle jerk and extensor plantar reflex) and when standard diagnostic work-up (MRI of the lumbar spine, EMG and NCS, standard laboratory screening for most common causes of foot drop) is negative or inconclusive. Although very rare, central lesions present a far more serious cause of foot drop and require a more urgent diagnostic work up and a potential neurosurgical referral and treatment. Keeping in mind the possible central causes of foot drop would eliminate unnecessary diagnostic work up and avoid delayed diagnosis and treatment.

The Interdisciplinary Management of Foot Drop

BACKGROUND

Foot drop can be caused by a variety of diseases and injuries. Although it is a common condition, its overall incidence has not been reported to date. Foot drop markedly restricts the everyday activities of persons suffering from it. There is, therefore, a need for an optimized strategy for its diagnosis and treatment that would be standardized across the medical specialties encountering patients with this problem.

METHODS

This article consists of a review on the basis of pertinent publications re- trieved by a search in the Pubmed/MEDLINE and Cochrane databases, as well as a description of the authors' proposed strategy for the diagnosis and treatment of foot drop.

RESULTS

Foot drop can be due to a disturbance at any central or peripheral location along the motor neural pathway that terminates in the dorsiflexor muscles of the foot, or at multiple locations in series. Optimal localization of the lesion(s) is a pre- requisite for appropriate treatment and a successful outcome. The most common causes are L5 radiculopathy and peroneal nerve injury. An operation by a neuro- surgeon or spinal surgeon is a reasonable option whenever there is a realistic chance that the nerve will recover. In our opinion, any patient with a subjectively disturbing foot drop and a clinically suspected compressive neuropathy of the peroneal nerve should be informed about the option of surgical decompression of the nerve at the fibular head, which can be performed with little risk. In case of a permanent foot drop, some patients can benefit from muscle-transfer surgery. For spastic foot drop, the option of botulinum toxin injections should be evaluated.

CONCLUSION

The care of patients with foot drop could be optimized by interdisciplin- ary foot-drop clinics involving all of the relevant specialists. The goals of treatment should always be improved mobility in everyday life and the prevention of falls, pain, and abnormal postures.

An Unusual Presentation of Chronic Subdural Hematoma with Isolated Footdrop

BACKGROUND

Patients with chronic subdural hematoma (CSDH) typically present with symptoms of increased intracranial pressure, including headache, nausea/vomiting, and somnolence, or with contralateral weakness. Compression of the convexity cerebral cortex usually causes motor deficit that is more readily appreciated in the upper extremity rather than in the leg, and very subtle deficit may be detected only by looking for pronator drift. The precise pattern of signs and symptoms in CSDH may vary from case to case depending on the specific anatomy of compression, but isolated lower extremity weakness is rare.

CASE DESCRIPTION

A 79-year-old woman presented with isolated footdrop. CSDH overlying the cerebral convexity was detected on computed tomography. The foot weakness resolved on surgical drainage.

CONCLUSIONS

CSDH overlying the cerebral convexity may manifest with isolated foot weakness. Awareness of the potential for this unusual presentation of CSDH may be useful to the clinician assessing a patient with otherwise unexplained foot weakness.

Analysis of stress application at the thoracolumbar junction and influence of vertebral body collapse on the spinal cord and cauda equina

The thoracolumbar junction comprises the spinal cord, nerve roots and the cauda equina, exhibiting unique anatomical features that may give rise to a diverse array of symptoms under conditions of injury, thus complicating the diagnosis of compressive disorders. The present study aimed to examine varying degrees and forms of compression at this level of the spinal cord using a two-dimensional model to calculate the relationship of these variables to injury. The degree of compression was expressed as a percentage of the spinal canal that was occupied. Results were compared with findings from clinical observations to assess the validity of the model. Analysis revealed that higher levels of compression/spinal canal occupation are associated with the presence of neurological symptoms. This finding was consistent with clinical data. Results of the present analysis warrant further research involving evaluation of compression with respect to other parameters, such as blood flow, as well as more anatomically accurate three-dimensional analysis.

The management of weakness caused by lumbar and lumbosacral nerve root compression

Spinal stenosis and disc herniation are the two most frequent causes of lumbosacral nerve root compression. This can result in muscle weakness and present with or without pain. The difficulty when managing patients with these conditions is knowing when surgery is better than non-operative treatment: the evidence is controversial. Younger patients with a lesser degree of weakness for a shorter period of time have been shown to respond better to surgical treatment than older patients with greater weakness for longer. However, they also constitute a group that fares better without surgery. The main indication for surgical treatment in the management of patients with lumbosacral nerve root compression should be pain rather than weakness.

Spastic foot-drop as an isolated manifestation of neurocysticercosis

Foot-drop is a rare but important manifestation of intracranial pathologies ranging from space-occupying lesions to cerebrovascular accidents. Being most commonly associated with peripheral nerve lesions or radicular compressions, it remains an underappreciated feature of central-structural abnormalities. We describe an interesting case of a 14-year-old boy who had presented with acute onset right-sided foot-drop due to a left-sided parasagittal neurocysticercus lesion, without seizures and discuss the location of the lesion in the precentral area in reference to Penfield's motor homunculus.

Bilateral Footdrop After Treatment of an Anterior Communicating Artery Aneurysm: A Case Report and Review of the Literature

Background And Importance:

Footdrop designates weakness of the ankle as well as toes dorsiflexion. Peripheral causes of unilateral footdrop are well established. Bilateral footdrop originating from pathologies in the central nervous system are rare and include a number of unexplored etiologies.

Clinical Presentation:

A case of bilateral footdrop is presented. The patient presented with a grade IV subarachnoid hemorrhage with intraventricular extension. He was treated with coil embolization of an anterior communicating artery aneurysm. Postoperatively, he was found to have weakness of both ankle and toe dorsiflexion. Findings on magnetic resonance imaging of the cervical, thoracic, and lumbar spine were negative for abnormal cord signal, cord infarction, and compressive lesion. Magnetic resonance imaging of the brain revealed parasagittal bifrontal and right greater than left convexity foci of acute infarction.

Conclusion:

Central causes of acute footdrop are rare. However, they should be considered in the differential diagnosis, particularly in the presence of upper motor neuron signs on physical examination.

Clinical features of central isolated unilateral foot drop: A case report and review of the literature

Background:

Intracranial cause of isolated unilateral foot drop is very rare. There may be a delay in the diagnosis of the cause of central foot drop or patients with such lesions might be misdiagnosed and subjected to unnecessary interventions. One of the reasons for the diagnostic uncertainty might be the absence of upper motor neuron (UMN) signs in the initial examination of such patients.

Case Description:

We present a very rare case of a 78-year-old woman who had presented with a five-year progressive right-sided unilateral isolated foot drop from a left-sided parasagittal tumor. Previously, she had undergone biopsy of an abnormality on the right C7/T1 facet, which was found to be benign. On examination of the patient, she had UMN signs in the ipsilateral foot. On magnetic resonance imaging scan of her head, a 3-cm left parasagittal lesion, consistent with it being a meningioma, was noted. The patient had significant medical history and declined to undergo surgical removal of the lesion.

Conclusion:

We review the literature on central foot drop from various intracranial pathologies and discern its clinical features. Patients with central foot drop often have UMN signs; however, these may be absent causing diagnostic uncertainty, and physicians should be vigilant of these variations in the presentation.

Delayed diagnosis of brain tumor in a patient with flexor spasms and spastic foot drop

Flexor spasms are involuntary muscle contractions comprising dorsiflexion at the ankle and flexion at the knee and the hip, occurring as a result of nociceptive spinal release reflex. The presence of flexor spasms generally suggests a lesion in the spinal cord. Foot drop is usually seen with lesions of lumbosacral roots, peripheral nerves or muscles. We hereby present a patient with a rare combination of spastic foot drop and flexor spasms due to a brain tumor. The possible underlying pathophysiological mechanisms resulting in flexor spasms due to a cerebral lesion are briefly discussed.

Foot drop due to lumbar degenerative conditions: mechanism and prognostic factors in herniated nucleus pulposus and lumbar spinal stenosis

OBJECT

The aim of this study was to analyze the mechanism and prognostic factors of foot drop caused by lumbar degenerative conditions.

METHODS

The authors retrospectively reviewed the charts of 28 patients with foot drop due to a herniated nucleus pulposus (HNP) or lumbar spinal stenosis (LSS), scoring between 0 and 3 on manual muscle testing for the tibialis anterior muscles. They analyzed the mechanism of foot drop and whether the duration before the operation, preoperative tibialis anterior and extensor hallucis longus strength, age, gender, and diabetes mellitus were all found to be prognostic factors for postoperative tibialis anterior recovery. They also investigated whether the diagnosis had any influence on the prognosis.

RESULTS

The compression of double roots and a sequestrated fragment were observed, respectively, in 9 and 13 of 16 patients with HNP. Multiple levels including the L4-5 segment were decompressed in 8 of 12 patients with LSS. Analysis did not demonstrate any prognostic factor in surgically treated HNP, but significant associations with prognosis were observed with respect to preoperative tibialis anterior (p = 0.033) and extensor hallucis longus (p = 0.020) strength in patients with LSS. In addition, the postoperative muscle recovery in patients with HNP was significantly superior to that in patients with LSS (p = 0.011).

CONCLUSIONS

Double root compression was the most common condition associated with foot drop due to HNP. The diagnosis and preoperative tibialis anterior and extensor hallucis longus strength in LSS were factors that influenced recovery following an operation.

Foot drop: The first sign of an intracranial tumor?

Isolated foot drop due to a brain lesion is rare. A 48-year-old man complained of inability to dorsiflex the right foot. Right dorsiflexion had 0/5 muscle strength and there were no upper neuron findings on his neurological examination. Magnetic resonance imaging of the brain revealed a left parasagittal brain mass. The lesion was removed and muscle activity returned with 3/5 muscle strength 6 weeks after the operation. The parasagittal area is located at the foot of the homunculus. Therefore, in patients with foot drop, lesions of the parasagittal area should be considered.

Surgical outcome of drop foot caused by degenerative lumbar diseases

STUDY DESIGN

A total of 46 patients undergoing lumbar spine surgery for degenerative lumbar disease and presenting with drop foot were included in this retrospective study.

OBJECTIVE

To determine which preoperative patients' symptoms were of statistical significance in their effect on surgical outcome.

SUMMARY OF BACKGROUND DATA

Drop foot is a neuromuscular condition that results in palsy of the ankle dorsiflexion and is a major problem in Japanese daily life. Few studies have described the effect of a surgical intervention on drop foot associated with degenerative lumbar disorders and the factors that affect the surgical outcome. The manual muscle test can be used to determine the muscular strength of the tibialis anterior. Drop foot is then defined as a score below 3 out of 5.

METHODS

Patient medical history, preoperative tibialis anterior strength, presence of leg pain, and duration of palsy were recorded and compared with surgical outcome.

RESULTS

Of patients, 61% recovered from drop foot after surgery. Patients with a tibialis anterior score of 2-3- and those suffering from palsy for a shorter duration of time showed better surgical results. Cases without leg pain were also shown to be treated effectively with surgery.

CONCLUSIONS

Palsy duration and preoperative strength were factors that most affected drop foot recovery following surgical intervention for spinal degeneration.

Cerebral infarction producing sudden isolated foot drop

Foot drop usually results from lesions affecting the peripheral neural pathway related to dorsiflexor muscles, especially the peroneal nerve. Although a central nervous system lesion is suspected when there is a lack of clinical evidence for a lower motor neuron lesion, such cases are extremely rare. We describe a patient with sudden isolated foot drop caused by a small acute cortical infarction in the high convexity of the precentral gyrus. This report indicates that a cortical infarction may have to be considered as a potential cause of foot drop.

Central causes of foot drop: rare and underappreciated differential diagnoses

BACKGROUND/OBJECTIVE

Peripheral causes of foot drop are well recognized. However, causes stemming from the central nervous system represent rare, important, and underappreciated differential etiologies.

METHODS

Two cases of foot drop stemming from central causes are described.

PATIENTS

The first patient, a 46-year-old man with a remote history of lumbar spine fracture and L4-L5 instrumentation/fusion, presented with progressive weakness and numbness of the left foot, followed within 3 months by similar symptoms in the right foot. Lumbar spine imaging failed to reveal compressive nerve root pathology. Electromyography, nerve conduction studies, and muscle and nerve biopsy suggested a preganglionic lesion and ruled out a peripheral cause. Upper spine magnetic resonance imaging (MRI) revealed significant spinal stenosis at C4-C7 and T11-T12. Patient 2 was a 66-year-old man with a known left parasagittal convex meningioma diagnosed 2 years prior presented with a progressive right foot drop over 2 months. Spine imaging was normal, and serial brain MRI confirmed a slowly enlarging parasagittal meningioma.

RESULTS

Following decompressive laminectomies at C4-C7 and T11-T12, patient 1's gait improved, with marked resolution of his right foot drop and significant improvement on the left. Patient 2 underwent craniotomy for microsurgical tumor resection. At the 2-week follow-up examination, he was taking daily walks.

CONCLUSIONS

Central causes, although rare, need to be considered in the differential diagnosis of foot drop. Central causative lesions usually occur at locations where pyramidal tract connections are condensed and specific and the function is somatotopically organized. These cases confirm that good results can be achieved when correctable central causes of foot drop are recognized.

Improvement of preoperative foot drop after lumbar surgery

Foot drop is a common and debilitating finding in patients with lumbar spinal disorders. Recovery of function after surgical treatment of the underlying disorder is not well documented in the literature. The purpose of this retrospective study was to analyze the prognosis of preoperative foot drop after lumbar surgery in 55 patients with foot drop and herniated nucleus pulposus and/or lumbar spinal stenosis. Preoperative dorsiflexion motor strength improved measurably in 98%, and 71% had full recovery of strength. All patients had associated neurologic findings and 71% experienced complete resolution. No statistically significant relationship was found between the extent of recovery and age, diagnosis (herniated nucleus pulposus lumbar spinal stenosis), duration of symptoms, or severity of preoperative weakness. In our series, the prognosis of preoperative foot drop and associated neurologic deficits treated by lumbar spine surgery was excellent.