Here's an interesting case for you...

Six year old male presents with his mother with a c/o abnormal gait and spasm of the right foot since having a right sided open herniectomy.

Birth Hx:  born C-section at 41.5 weeks, normal to advanced physical and intellectual development

PMH:   None

PSH:    adenotonsillectomy age 2, right inguinal herniectomy age 4

ALL:    NKDA, Peanuts

He had bilateral exploratory lap with subsequent open right inguinal herniectomy. On the 3rd post-op day he tried to walk upright and was noted to be dragging the right foot.  There was no pain and the drag was intermittent.  At times the gait appeared as a foot drop, steppage, or circumductory gait (all right side only), but most of the time his gait was normal. 

Within a few weeks the child started inverting and everting the right foot in a tic-like pattern, and it would rigidly contract in a PF-INV position when passively flexed.  On several occasions he had complaints of tingling all over his body. 

The condition was intermittent and stable for 2 to 3 months, then became suddenly worse, with the child dragging his right foot about 95% of the day and tripping several times a day.  He indicated no pain or discomfort, and was able to play/run/jump with little inconvenience.

Within another month or two he developed minor phonic tics. 

There was full muscle power of all muscle groups from the hip down and no sensory deficit or hyperesthesia.  There was no clonus.  Orthopedic exam showed a moderate bilateral, asymptomatic flexible flatfoot and pronatory gait.  An attempt to DF the foot caused the foot to spasm in rigid PF-inversion.

He was tested for a PANDA, arthritis, Lyme dz, lead level, etc and all tests were normal.

The problem was not present during sleep, and improved when the child focused intensely on an activity.  It is worse when the child is tired.  The right foot symptoms improved dramatically with a velcro ankle brace ($10) and several physical therapy/aquatherapy appointments.  It recurred 8 months later and again disappeared after a few days of physical therapy.

Neither the general surgeon nor the pediatrician knew what to make of it.  There were 3 pediatric neurologists consulted on the case.  They're conclusions were that it was a tic with elements of a focal dystonia. 

If  this is a tic, why is there spasm?  If it's a dystonia, why is it intermittent and improves with PT?  Why does it improve with an ankle brace and/or a few PT sessions?  What about the tingling sensations?  Neither tics nor dystonia are associated with tingling as far as I know.  Why does the foot spasm with passive DF?  Why did it start right after the herniectomy?  Why did it appear to resolve and then suddenly reappear?

Any thoughts?

  • Comments (3)
  • Check out dystonia musculorum deformans

  • Quote:

    I would say that it sounds like, obviously, there was a CNS deficit that occured during surgery.

    Dave Gottlieb, opinions mainly as a parent.

    Thanks Dave, that was helpful.  It's along the lines of what I was thinking as well, but none of the doctors mentioned it or even entertained that it was surgically related, other than that it was the stress of the surgery that brought out the "tic".  It's as if they are afraid that if they link it to a surgery that there will be a law suit.  The mother just wants to know what it is, what caused it and if it will be progressive.  The child's symptoms have disappeared again, after just a few days of PT (other than minor phonic tics).

  • Not being a neurologist I would think that the plasticity of the growing child's nervous system would account for the improvement/regression cycle and I would look at the over all trend as to prognosis.

    As the parent of a child/adult with cerebral palsy I would say that it sounds like, obviously, there was a CNS deficit that occured during surgery. My experience with neurologists and neurosurgeons is that they are decidedly focused in what they look for and have a HUGE aversion to giving parents bad news.

    My suggestion is find a pediatric neurodevelopmentalist for a work up.

    Dave Gottlieb, opinions mainly as a parent.