Patient is a 76 year-old man with a four-year history of progressive gait disturbance, urinary urgency and memory deficit. His gait disturbance is his primary complaint, which he describes as slow, shuffling and off balance with easy fatigability. He takes very short steps and feels as if his feet are trying to catch up with his forward moving body. He occasionally has fallen but without injuring himself. With any illness or even a cold, his symptoms worsen to the point of being unable to support his weight in a standing position otherwise he often uses a cane or a walker to ambulate.
Serial CT scans have shown mild ventricular enlargement and lumbar tap resulted in significant resolution of his symptoms for 24 hours. Neurosurgical consultations have unanimously recommended a shunting procedure to divert cerebrospinal fluid into the abdomen.
Past Medical/Surgical History: Gastroesophogeal reflux disease, lumbar spinal stenosis, hyperthyroid (post thyroidectomy), benign prostatic hypertrophy, cardiac pacemaker x 2 with one episode of endocarditis due to a staph infection, cholecystectomy
Medications: Tapizole, aciphex
Physical Exam: Mental status exam revealed slight forgetfulness. Muscle tone, strength sensation, coordination were all normal. There was slight decrease in vibratory perception in his toes bilaterally but position sense was intact. Deep tendon reflexes were all essentially normal. Gait demonstrated small shuffling steps with slight increase in his base.
Discussion: Lumbar stenosis does not appear to explain this patient’s gait disorder and with the dramatic response to lumbar puncture, normal pressure hydrocephalus is the most likely diagnosis. The patient has consulted with numerous neurology and neurosurgical specialists who all concur with this diagnosis and the recommended treatment by surgical shunting of the CSF. He has participated in an ongoing exercise program without much success and has received Osteopathic treatment with surprising results.
His son is a recognized authority in the field of Osteopathic Manipulative Medicine, and had noticed a temporary but significant response to his sporadic treatments, similar to that of the lumbar puncture, that lasted 2 to 6 hours after treatment. The patient arranged at his son’s request, to stay a week in his home and receive daily treatments. The treatments resulted in a similar immediate improvement, which was sustained due to the daily administration of these treatments. After the third day of treatment the patient became weak and that night fell out of bed. He could not be helped to his feet and ran a slight temperature of 99.6. His mental status was confused. Paramedics were called and in the E.R. his temperature was 103 and his white count 39,000. It was related by the patient’s spouse that he had a persistent cough for the previous 2 weeks, which was treated with Zithromycin, but was still lingering. He was admitted and given triple antibiotic therapy. His temperature and white count resolved within 36 hours and he was discharged with a tentative diagnosis of pneumonia. However, chest X-ray did not show infiltrates and urine, blood and CSF cultures were all negative. An echocardiogram was performed to consider a cardiac source of infection, but none was found.
After discharge the patient returned to his son’s home without return of his gait problems and has been walking normally ever since. He reports a dramatic increase in physical and mental energy that he has not experienced in years and states that his urinary urgency is completely gone.
It is well known that hydrocephalus often follows a blow to the head, although the exact mechanism for this is not well understood. Osteopathic assessment of the movement of cranial bones can localize areas of compression often associated with trauma. This compressive force often leads to meningeal tension and twisting and may result in impingement of vascular or neural structures or even impair CSF flow through displacement of tissue in the subarachnoid space or within the ventricular cisterns and channels. The presence of such compression was evident in this patient between the left sphenoid and temporal bone at the sphenosquamous suture. Treatment involved decompression of the area and subsequent stimulation of CSF fluctuation using Osteopathic manipulative techniques. On the third day of treatment a particularly large fluid fluctuation was perceived during the treatment when the sphenosquamous suture was finally released. Subsequent daily Osteopathic exams over the next 6 days showed no return of this compression, and the patient continued to enjoy full symptom-free motor, urinary and cognitive function. The results are compelling and certainly deserve further study.