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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Localization Of Bilateral Leg Weakness
- Bilateral leg weakness usually localizes to the spinal cord or below, not the brain.
- Consider spinal cord, cauda equina, nerve roots, neuromuscular junction, or muscle when legs are primarily affected.
Use Exam To Guide Localization
- On exam, differentiate upper versus lower motor neuron signs and presence of reflexes to localize pathology.
- Use sensory findings and reflex patterns to distinguish neuropathy, myopathy, or spinal cord disease.
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.
