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

by Dr. Brion Reichler

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.