The Clinical Problem Solvers Episode 438: Neurology VMR – Bilateral Leg Weakness
Jan 15, 2026
In this enlightening discussion, Andrew Sanchez, a hospitalist-educator, presents a perplexing case of bilateral leg weakness while Aaron Berkowitz, a neurologist, guides the analysis through differential diagnoses. Sarah K Blaine, an aspiring neurologist, joins the conversation, exploring the nuances of spinal versus peripheral causes and the significance of symptoms like weight loss and atrophy. The group delves into diagnostic strategies, discussing the implications of lab results and imaging in pursuit of clarity amidst uncertainty.
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Atrophy Favors Peripheral Process
- Diffuse muscle atrophy with relatively preserved sensation suggests a lower motor neuron or peripheral process.
- Atrophy typically points to peripheral nerve disease or longstanding disuse rather than pure neuromuscular junction disease.
When Atrophy Outpaces Sensory Loss
- Severe atrophy out of proportion to sensory loss raises concern for motor neuron disease.
- Motor neuron disease can mimic peripheral nerve disorders and should remain on the differential.
Give IV Thiamine Early
- In suspected nutritional neuropathy, start empiric IV thiamine before waiting for labs.
- Consider beriberi and other vitamin deficiencies in subacute neuropathies with malnutrition.
