Abstract
Idiopathic normal pressure hydrocephalus (iNPH) is a progressive neurological disorder characterized by gait apraxia, cognitive decline, and urinary incontinence. It can be difficult to diagnose iNPH as the symptoms may overlap with other neurodegenerative diseases including cervical spondylotic myelopathy. Cervical spondylotic myelopathy is a progressive degenerative disease in which compression of the cervical spinal cord causes gait disturbances and imbalance, loss of dexterity and strength in the hands, and, at late stages, urinary dysfunction. As with iNPH, increased age is associated with higher incidence and prevalence. Surgical decompression of the cervical spinal cord is the treatment of choice in patients with progressive myelopathy. Accordingly, iNPH and cervical myelopathy may both present with progressive gait impairment and incontinence, especially in the elderly.The case presented here demonstrates that both iNPH and cervical myelopathy may present simultaneously and result in gait disturbances and imbalance in some patients. For patients with suspected iNPH and myelopathic findings on examination, it is prudent to obtain a cervical spine MRI to assess for cervical stenosis. Moreover, cervical stenosis can mask the effect of cerebrospinal fluid diversion in patients with comorbid iNPH and cervical myelopathy. Therefore, the differential for patients who have symptomology suggestive of iNPH should include cervical spine myelopathy, with considerations for possible cervical decompression in addition to placement of a ventriculoperitoneal shunt.
Highlights
The case presented here demonstrates that both idiopathic normal pressure hydrocephalus and cervical myelopathy may present simultaneously and result in gait disturbances and imbalance in some patients
Idiopathic normal pressure hydrocephalus is a progressive neurological disorder characterized by gait apraxia, cognitive decline, and urinary incontinence
It can be difficult to diagnose Idiopathic normal pressure hydrocephalus (iNPH) as the symptoms may overlap with other neurodegenerative diseases including cervical spondylotic myelopathy
Summary
The case presented here demonstrates that both idiopathic normal pressure hydrocephalus (iNPH) and cervical myelopathy may present simultaneously and result in gait disturbances and imbalance in some patients. He continued to suffer progressive deterioration of his gait and balance over the ensuing year, and returned for repeat lumbar tap test Prior to this second high-volume lumbar puncture, the patient took 31.1 seconds on average to walk 10 meters (SD: 3.6 seconds; n = 4) and an average of 7.6 steps per 180 ̊ turn. The difference in time to complete a 10-meter walk (Video 1) before and after lumbar puncture was statistically significant (p < 0.01), as was the number of steps per 180 ̊ turn (p < 0.01), both determined using a two-tailed Student’s t-test Based on this clear response to temporary CSF removal, the patient underwent placement of a right parietal ventriculoperitoneal shunt. The patient was no longer using a walker and just used a cane when outside the house and had not fallen
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