Physical Medicine and Rehabilitation The Mayo Clinic Jacksonville, Florida, United States
Case Diagnosis: Diabetic lumbosacral radiculoplexus neuropathy
Case Description: A 63 year old female with a medical history significant for type 2 diabetes mellitus diagnosed 9 months prior after hospitalization for diabetic ketoacidosis presented in clinic for evaluation of low back pain. She noted mild bilateral low back pain starting two months after hospitalization initially localized to the left and then bilateral hips and anterior thighs, which felt burning/sharp. Difficulty with sit to standing. She noted a 30-pound weight loss since her diagnosis of T2DM 9 months ago, with associated gastrointestinal issues of alternating diarrhea and constipation. She noted weakness of the right hip flexor, bilateral 2/5 on MMT with marked atrophy. Absent bilateral lower limb reflexes. NCS/EMG showed length dependent sensorimotor peripheral neuropathy primarily axonal in nature, with possible superimposed chronic right L5 radiculopathy. MRI lumbar spine from 4 months ago revealed multilevel lumbar disc and facet degeneration with no significant disc protrusion and multilevel stenosis.
Discussions: Considering the patient’s recent diagnosis of diabetes and prompt glycemic control the patient achieved after her hospitalization, Hg A1c 6.7, in conjunction with her presentation of asymmetrical progression of pain, motor weakness, proximal muscle atrophy, weight loss, and areflexia, her story is clinically suggestive of diabetic lumbosacral radiculoplexus neuropathy. NCS/EMG did not demonstrate significant lumbar spine abnormality. MRI lumbar spine lacked evidence of significant lesion or compression resulting in proximal lower extremity symptoms. Currently following with her local endocrinologist and neurologist, she is not in pain and her strength has improved 90% with physical therapy. She is regaining weight.
Conclusions: Diabetic lumbosacral radiculoplexus neuropathy is a rare presentation of chronic back pain that is self-limited but may last over two years and leave residual motor deficits. If not appropriately diagnosed, possible complications include progression to paraplegia or quadriplegia, development of depression, anxiety, and unnecessary spinal surgery.
