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Abnormal Movements of the Back Heralding Amyotrophic Lateral Sclerosis

A 56-year-old Andean highlander was brought by his family for evaluation of abnormal movements of his back, of which he was unaware (Video 1). He denied dyspnea. The rest of the examination revealed widespread upper and lower motor neuron signs. Nerve conduction and electromyography studies were consistent with clinically definite amyotrophic lateral sclerosis (ALS) (Tables 1 and 2). Blood gases revealed chronic, compensated respiratory insufficiency appropriate for high altitude (4300 meters above sea level). Abnormal movements of back muscles have been reported after injury. They may also result from activation of accessory respiratory muscles to compensate for diaphragmatic weakness or chronic respiratory insufficiency, which is a rare presentation of ALS.