Unsteady walking for two days in a 32-year-old: an ataxia case to work up

Why unsteady walking matters

Unsteadiness can come from the cerebellum, the sensory nerves, the inner ear or weak legs, and each points somewhere different. A careful examination usually tells you which, and that decides how fast she needs imaging.

What to ask in the history

• When it started and whether it is getting worse
• Worse in the dark or with eyes closed
• Spinning, hearing loss, ringing in the ears
• Double vision, slurred speech, trouble swallowing
• Numbness, weakness
• Headache, vomiting
• Recent infection or vaccination
• Alcohol, medicines
• Previous neurological episodes, such as loss of vision

Red flags

• Sudden onset
• Severe headache or vomiting
• Drowsiness
• Double vision, swallowing difficulty
• Weakness that is spreading, or breathing difficulty
• Signs on one side only

What to examine

• Gait, heel-to-toe walking, Romberg's test
• Eye movements and nystagmus
• Speech
• Finger-nose, heel-shin, rapid alternating movements
• Tone, power, reflexes
• Vibration and joint position sense
• Hearing, and the fundi

First investigations

• Glucose, electrolytes, full blood count, vitamin B12
• MRI of the brain
• Further tests guided by the findings: lumbar puncture, nerve conduction studies
• Alcohol or drug levels if relevant

Differential diagnosis of unsteady walking

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

Common mistakes

• Blaming the inner ear without testing for cerebellar signs.
• Skipping Romberg's test.
• Missing a stroke in the back of the brain because she is young.