The surgical walk

Yoursquove got a compression in your thoracic spinerdquo I proclaimed as I saw 68yearold Mr Shaikh shuffle towards the door of my consulting room that I was holding ajar for himHe wore a white kurta and adorned a long stringy silvery beard to go with it I usually refrain from making any diagnosis until I listen to a patientrsquos complete history and perform a detailed examination but his short stiff steps that seemed a little out of his own control gave it away His wife held one arm while I firmly gripped the other as we gently helped him into his chair and allowed him to tell me why he was hereldquoIrsquove been diagnosed with Parkinsonrsquosrdquo Mr Shaikh said ldquoIrsquove been taking medication for a while but its only getting worse I was feeling better than James Bond just a few years agordquo he lamented remembering an earlier healthier time He appeared fidgety with his hands which was probably assumed to be a tremor by his treating doctor Patients with Parkinsonrsquos have an extremely stoic looking face often deadpan and they blink very little but he seemed pretty animated in expressing his difficulty in walking ldquoDo you wake up in the middle of the night and shout sometimesrdquo I asked some patients with Parkinsonrsquos have a sleep behavioural disorder ldquoShe does thatrdquo he jested pointing to his wife ldquoThatrsquos because he gets up and turns the light on every few hours to pass urinerdquo she said giving me another clue in the puzzleI examined him to find his upper limbs devoid of the usual rigidity that we expect in Parkinsonrsquos but his legs were stiff as logs While he sat on the examining bed facing me I tapped on his knees with a neurological hammer and his feet briskly sprung up in the air and back If you are positioned directedly in front of a patient while doing this you can injure vital parts of your anatomy but with experience you learn where to stand However as I remember reading somewhere experience is something Irsquod like to have without going through all the trouble of getting itldquoSometimes progressive degenerative conditions of the brain and spine have several mimicsrdquo I finally asserted and to confirm my suspicion continued with ldquoIt would be best to get an MRI of the spinerdquoHe returned within a few weeks this time taking a little longer to position himself than he did the last time he was here ldquoYoursquore right doctor the report does mention severe compressionrdquo he said while his wife handed over the MRI films to me I slid the scan into the groove of the light box and showed them where the ligament over the fourth and fifth thoracic vertebrae had thickened thinning the spinal cord considerably This MRI visual is one that most patients seem to intuitively understand instantly relating it to being responsible for their symptoms ldquoThis will need an operation Mr Shaikh Wersquoll position you on your belly make an incision over the upper part of your back drill off the bone and bite off the thickened ligament giving the spinal cord its rightful space Over the next few months your gait will improve dramaticallyrdquo I said confidently ldquoWill I go back to being James Bondrdquo he wondered aloud ldquoShaikhen but not stirredrdquo I punned but he didnrsquot smile Irsquoll admit it wasnrsquot a very good jokeWe operated on him a few days later We cut down from skin to bone cleanly dissecting the muscle off it I then drilled a trough on either side of the bone and lifted the back of the vertebra in a single piece We nibbled all over the thickened ligament as the compressed covering of the spinal cord finally came to the surface one bite at a time assuming its normal rounded position free and breathing easy ldquoI already feel less tight in my legsrdquo he muttered in his partly conscious state as we wheeled him out of the operating room A few months later when he came in to see me he looked several years younger His walk was swift and smooth with perfect cadence and in complete control ldquoDo you feel like James Bond nowrdquo I asked after seeing him so relieved and happy ldquoI just bought an Aston Martinrdquo he quippedIn any patient who has a problem walking diagnosing it rightly is the key to successfully treating it I remember as a child standing with my dad on the balcony of our home and identifying gait disorders We have a garden in front of our house and as the number one advice given by any doctor to someone who has a walking problem is that the patient should take a walk we were treated to a spectrum of ailments we had fun identifying Sometimes when I disagreed with my dad I would run down to ask the person walking if what he had was indeed what my father said he did and was amazed by his clinical acumen when we got an affirmative answer There was someone who would walk a few quick steps then freeze and then repeat the pattern ldquoThatrsquos the propulsive gait of Parkinsonrsquosrdquo my dad taught me when I was eight Then there was someone who would swerve his leg out with every step ldquoThis guy has had a stroke and residual hemiparesisrdquo I learntPeople who have an excess accumulation of fluid within the ventricles tend to walk with a broadbased gait as if their feet were refusing to leave the ground The gait is referred to as magnetic and is seen in patients with a condition called normal pressure hydrocephalus Patients who have a foot drop slap their foot on the ground making a distinct sound often just hearing not seeing a patient walk can establish the diagnosis A painful or an antalgic motion could either be because of arthritis of the knee or hip or spinal stenosis and often patients can have both my orthopaedic colleague and I have constantly discussed the overlap Children with cerebral palsy have a scissoring gait where their feet crisscross while walkingAfter thus learning about different kinds of gaits as a medical student I once took profound responsibility for the knowledge I had and went up to someone in the garden across my house I told them they walked this way because they had a slipped disc and needed to be urgently evaluated ldquoIrsquom sorry young manrdquo the elderly gentleman kindly told me putting his best foot forward ldquoItrsquos just a shoe bite from an illfitting shoe Irsquom dealing withrdquoThe writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals