Case Diagnosis: A 44 year old female who presents for hip pain found to have a new diagnosis of spastic cerebral palsy.
Case Description or Program Description: A 44 year old female presented to clinic with several years of hip pain, preceded by bilateral total hip arthroplasty (THA) approximately 10 years prior to presentation. Further discussion revealed the patient had spinal meningitis requiring hospitalization at 3 weeks old, followed by hip dysplasia requiring osteotomy at 2 years old and later THA as above. The patient was never assessed for a remote or primary neurological insult. In clinic gait analysis revealed spastic diplegic gait pattern, bilateral lower extremity spasticity, with clinical history concerning for cerebral palsy. Magnetic resonance imaging (MRI) of the head was ordered.
Setting: General outpatient physiatry clinic.
Assessment/Results: MRI head demonstrated severe ventricular dilation, concern for communicating hydrocephalus, and the radiologist expressed concerns for spinal webbing from remote spinal meningitis. The patient was evaluated with gait assessment prior to and after a high-volume lumbar puncture. Patient underwent ventriculoperitoneal shunt placement, physical therapy, and lower extremity onabotulinumtoxin A injections. A follow up computed tomography (CT) scan 1 year after shunt placement revealed similar hydrocephalus while the patient had marked clinical improvement in gait, cognitive function, and spasticity in the setting of a multidisciplinary treatment. It was determined that her ventricular dilation was chronic and likely permanent but that the pressure associated with the hydrocephalus was improved.
Discussion (relevance): This case represents the importance of a comprehensive history as well as appropriate gait assessment. Without thorough history and physical exam, this 44 year old patient may have continued without a proper diagnosis and treatment plan for her underlying, chronic spastic cerebral palsy due to severe hydrocephalus.
Conclusions: This is a rare case of late diagnosis of cerebral palsy over 40 years after the initial neurological insult.
.jpg)
