Ask the Expert: Dr. Brion Reichler, Neurologist, Answers Your Questions on Gait and Balance Disorders

by Dr. Brion Reichler
Dr. Brion Reichler, Neurologist

Q1. I had back surgery three months ago by a decent back surgeon. After the surgery his policy is to “turn over” the case to the hospital and in this case a city hospital. I can’t go back there for real reasons and he won’t talk with me. I have had no rehabilitation yet. My general doctor wants me to have some sort of balance test in a week (following lights or something)…why? What does that have to do with my lower back (nerve involvement). I am walking fairly well except for slight occasional pain. 

I cannot tell from your description why your doctor wants to test you or what kind of test he has in mind.   Pain is a common cause of altered gait, but if you are not having real balance issues, I do not see the utility.  Perhaps he found something on examination that you are not aware of.  I would inquire about the reason.  A good doctor should be able to explain the rationale for any test.

Q2. Can a herniated disc cause balance problems?   

A herniated disc can cause imbalance by two main mechanisms. One is weakness of the leg muscles, which could result from compression of the nerve roots (lumbar spine) or spinal cord (cervical or thoracic spine). Another common cause is spinal cord compression (cervical or thoracic spine), resulting in loss of sensation in the legs, especially joint position sense. In fact, imbalance, worse with visual deprivation, is one of the most common presentations of cervical cord compression – often in the absence of any neck symptoms.

Some general questions to ask yourself with balance problems:

-    Do your feet feel solidly in contact with the ground, or does it feel as if you are walking on foam or sand?

-    Is the imbalance worse in the dark or with your eyes closed (e.g., when washing your face in the shower)?

-    Is there any weakness?  Can you walk on your toes and heels?  Do you trip over your toes?

-    Is there any dizziness (i.e., a sense of movement, such as spinning or standing on a rocking boat)?

-    Are there associated symptoms of spinal cord disease, such as urinary frequency/urgency, weakness/atrophy of the hands, or jumpiness of the legs?

Q3. I was in a car accident that caused a whiplash. Then I started to have balance problems. Can the two be related? 

I am not aware of an association between whiplash and true balance problems.  However, if you have developed cervical spinal cord compression as a result, this could be the earliest sign (see question #2).  Dizziness is also sometimes reported after whiplash.  It is certainly common after head trauma, both in a mild form and as a more severe positional vertigo.  The former should be self-limited, while the latter sometimes requires a special non-invasive office procedure.  Clearly, it pays to have a formal neurological evaluation.

Q4. I have lupus and sometimes experience symptoms of dizziness and ringing ears. When I try to move I become unbalanced. Is that common?  

The vestibular system contributes to balance control by governing the body’s perception of its orientation in space and direction of movement.  It consists of the inner ear and its connections to the balance centers of the brain.  Vertigo or dizziness can result from disorders of both the brain (such as stroke, multiple sclerosis or trauma) and the inner ear, but more commonly the latter.  Ringing in the ears, or tinnitus (which is not always a ringing – sometimes a humming or buzzing) often goes along with inner ear problems.  Your symptoms are thus suggestive of an inner ear problem.  As to the relationship of these symptoms to your lupus, that is less clear.  Lupus patients often complain of a variety of non-specific symptoms of a neurologic nature that may have no correlation on physical examination or MRI – such as headache, dizziness and tingling in the limbs.  One study reported a higher prevalence of audiovestibular dysfunction in the lupus population.  However, the association remains poorly understood. Causes other than the lupus need to be ruled out, and you should see someone who specializes in dizziness, such as a neurologist or otolaryngologist – or even better, a neurotologist.

Q5. I have rheumatoid arthritis that causes peripheral neuropathy. Sometimes I trip over my toes. How would you treat my problem?

Peripheral neuropathy is not uncommon in patients with rheumatoid arthritis.  One study reported a prevalence of almost 40%, most of whom were asymptomatic.  This is generally a mild sensory neuropathy, which might be expected to cause numbness or tingling in the feet, and perhaps some related imbalance.  The fact that you are tripping over your toes is a bit more worrisome, suggesting the possibility of weakness, which is less common.  In addition to neuropathy, one needs to rule out cervical cord compression, which can be severe in the upper spine in RA patients.  You must also consider the possibility of a medication-induced neuropathy, as has been suggested with the anti-TNF-alpha agents, such as infliximab, in which case treatment may consist of discontinuing the medication.  Aside from this, there is no specific treatment for the neuropathy, other than treatment of the underlying condition.  Intravenous immune globulin (IVIg) infusions have proven useful in isolated cases and small series of patients with peripheral neuropathy in association with other autoimmune conditions, but is far from being an established treatment. Consult with your physician for treatment options.

Next week Alexis Waldbaum, Registered Dietitian and Nutritionist, will answer your questions on nutrition for male athletes. Write your question on the wall or email socialmediacontact@hss.edu.

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The information provided in this blog by HSS and our affiliated physicians is for general informational and educational purposes, and should not be considered medical advice for any individual problem you may have. This information is not a substitute for the professional judgment of a qualified health care provider who is familiar with the unique facts about your condition and medical history. You should always consult your health care provider prior to starting any new treatment, or terminating or changing any ongoing treatment. Every post on this blog is the opinion of the author and may not reflect the official position of HSS. Please contact us if we can be helpful in answering any questions or to arrange for a visit or consult.

Comments

manjunath says:

Hi in recent years i feel like balance disorder, feel like dizzy and blurred vision, sometime loss sense, doctor told this is bcz of anxiety disorder(GAD),

Stephen says:

Hello and thank you. I hope you can help me. My name is Stephen and I am concerned about my wife Victoria.

In January 2012, my wife fell walking up a stairs and fractured her right fifth metacarpal – nondisplaced. She also landed on her back and neck. She went to the hospital, got a splint and some percocet. A couple of weeks later she felt numbness in both hands, with her right hand still feeling weird (from the pain, I guess). Her orthopaedic doctor who changed the splint initially said it was just hormones. The numbness in both hands continued. We went to a number of other doctors, surgeons and a neurologist shortly after.

The neurologists report states the following:
Electomyography Impression:
Subacute bilateral cervical radiculopathies affecting the left C6 root as well as the bilateral posterior root innervated paraspinals. No active denervating potentials are demonstrated.
IMPRESSION from 112012 Trauma
1. .Cervical strain with referred sensory loss to the bilateral hands

The MRI report states the following:
– Posterior disk bulges. C5-C6 (2 mm) and C6-C7 (1-2 mm) levels.

Except for saying cervical strain and radiculopathies, the neurologist does not say why the numbness is there. The neurologist said that he would not recommend any procedures as there is no pain.
One spine surgeon (nationally recognized) states that the dermatones do not match up as the numbness should travel down the arms as well as the hands. He said the two disk bulges would not be enough to cover the whole of the hands (C8 bulge would also be needed apparently). He said he would not perform any surgeries or procedures.
Another spine surgeon said he would try an epidural injection in an attempt to reduce the numbness (it didnt sound convincing).
Another doctor has put forward the idea that it is due to Conversion Disorder.
A hand specialist has confirmed no carpal tunnel syndrome is present.

The questions I have are these:
1. Are the bulges enough to cause numbness in both hands?
2. If the damage to the nervous system is as stated, is it possible that the numbness could start only from the wrists down on both hands, with no symptoms up the arms?
3. If the bulges are “released” by an epidural injection is there a possibility the nerves can be repaired, and the sensation come back?
4.
5. What are your thoughts on the potential cause(s)?

Thank you very much for your time. I appreciate the time and any help you can give.

Stephen

HSS on the Move says:

Hi Stephen, thank you for reaching out to us. It is difficult to determine the cause of your wife’s numbness without a full evaluation. To make an appointment with a spine specialist, please contact Physician Referral Service at 877-606-1555 or visit them online at https://www.hss.edu/secure/prs-appointment-request.asp.

Mrs Sardar Fatima says:

my mom has suffering (SCI) or granlouma or milgnency because she is bed ridden and cant able to walk and move properly her legs due to spinal cord compression, in M.R.I they showed that D4 is totally collapse due to unknown reason, they suggested C.T Guided biopsy but this procedure has been failed due to lots of risk factors, now they started A.T.T so that granlouma can cure, all the investigation are not showing milgenency and tuberculosis, but something is here kindly give me suggestion what to do? i want u to give me advice to cure without surgery. thanks regards Babar ali from pakistan

HSS on the Move says:

We”re sorry to hear about your mother’s story. We can”t be sure that there is a non-surgical solution without a physical examination. If you are interested in visiting HSS for care, please contact our International Center for assistance: http://www.hss.edu/international-center.asp.

I”ve got tinnitus and it has been really upsetting me over the last few weeks, I lie awake at night, I”m irritable and keep getting angry with my kids. I found a online group which has a couple of useful tips.

karen says:

i have suffered from vertigo an spinal inflammation an headaches an vision an gait problems for 12 yrs. i am post menapausal , an i have severe sleep deprivation from menapausal symptoms night sweats ect. but i was diagnosed with somatoform . not somatization disorder . this is a mental problem . dont drs. understand hormones yet. i am having a hard time due to severe sensitivities to medications an hormone therapy. why do drs. call this a mental disorder. . i have same symptoms for 12 yrs. i know sleep deprivation can cause multiple symptoms. there is 40 known menapausal symptoms not all the same time .can u answer this an get back to me on your thoughts. thanks…….i am so stressed with this .

HSS on the Move says:

Hi Karen, thank you for your comment. If you would like to see a physician at HSS, please contact our Physician Referral Services at 877-606-1555.

JPH says:

Have scolosis taken me to many epidural injections lumbar and neck…how may is too many? Now heading it to HSS neurologist–as losing balance, a bit of tingling. What will a neurologist tell me that ur injection folks have not? What do u do that is different? Done carpal tunnel with no findings…have a consultation, but pls hope to walk out with a plan to tackle? –.been a long few months back and forth at HSS as not easy getting appointments…thank you.

HSS on the Move says:

Thanks for reaching out. Please email us at socialmediacontact@hss.edu so we can further assist you.

robert elgersma says:

hi sir My mri says. L4-5 there is a postererior disc/ annular tear and posterior shallow disk bulge slightly contacting theanterior surface of thethecal sac and junctiuon of the proximal left L5 nerve root. both my feet in lots of pain, right upper in side leg ,even the palms of my hand,tingling. 3 moths al my doc has given me is hydrocodone 325mg. please what kind of doctor am I need to see.pills are not helping to fix me ? thank you again for your time

HSS on the Move says:

Hi Robert, thank you for reaching out. It is recommended that you see a physiatrist so they can better advise. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

karen says:

My sister is going through her second bout of PAINFUL sciatica. 2 years ago it lasted almost a year,,,,,,It has returned and she is taking medication and having massages. Results are nil. Last year she even tried acupuncture. The massages seem to eventually alleviate the pain last year. My heart is breaking watching her in constant pain. once again. She says it is actually worse then the prior ‘attack’. What type of Dr. should she be seeing? ,,,,a Neurologist? Could you suggest one at HSS? I appreciate your time and consideration to this matter. Regards, Karen

HSS on the Move says:

Hi Karen, thank you for reaching out. For more information on sciatica, please visit http://www.hss.edu/condition-list_sciatica.asp. If your sister wishes to receive care at HSS, she should contact our Physician Referral Service at 877-606-1555 for further assistance.

PAMELA says:

Hi, my question is- can you have dizziness & balance problems with C2 & C3 herniated disc? I notice on my walks if I move to fast or turn head things spin & sometimes go dark for a second. I have a appointment with neurosurgeon on 16th. I’ve already had surgery in 2008 on C3 &C4. Thank you for your input & time.

HSS on the Move says:

Hi Pamela, thank you for reaching out. Dr. Han Jo Kim, Orthopedic Surgeon, says: “It is possible that your symptoms can be coming from the C2 and C3 levels. It might also be worthwhile to rule out the vertigo. Following up with a spine surgeon will be best for addressing your concerns. Be sure to bring detailed imaging to the visit- this will allow for a more thorough evaluation.” It is best for you to consult with your treating physician. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

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