MedPix Medical Image Database COW - Case of the Week Case Contributor: Michael D Casimir Affiliation: SUNY at Buffalo

MedPix No: History Pt Demographics: Age = 66 y.o. Gender = man This 66 y.o. man was the restrained driver involved in a motor vehicle collision in February. Following the accident, the patient felt pain in the neck, lower back, left knee, and left lower extremity. Fractures were ruled out in the ER and on the day following the accident, the patient received a chiropractic evaluation of his neck and low back pain. He initially rated the pain in his cervical region as 4/10. The patient received chiropractic treatments, including electrical stimulation and manipulative therapies, three times weekly. He had temporary, partial symptomatic relief, but continued to describe progressive pain in the cervical region. Approximately four weeks after the accident, the patient consulted with a pain management physician, and was given cyclobenzaprine 10 mg PO every eight hours as needed and hydrocodone/acetaminophen 7.5/500 mg PO every six hours as needed.Approximately 12 weeks after the accident, the patient rated his cervical pain as 6/10 at best and 8/10 at worst. At this time he also described numbness radiating down his left upper extremity into his hand and affecting the first three digits on the left side. The symptoms progressed, and the patient began to describe gait instability with loss of equilibrium and bilateral clumsy hands in addition to his left upper extremity paresthesias. Spinal surgical consultation was obtained. Given the findings of an MRI examination indicating disc extrusion at C4-C5, resulting in severe cervical spinal stenosis with cord compression, as well as the clinical findings suggestive of left upper extremity radiculopathy with myelopathic changes, surgical intervention with anterior discectomy and fusion at C4-C5 was advised.Surgery was performed on July 3rd. The patient continued to describe pain in the cervical region following surgery, which he rated initially as 8/10. His hydrocodone/acetaminophen dose was increased to 10/500 mg with the same dosing frequency. The pain increased to 10/10 in the cervical region, and his pain medication was changed to oxycodone/acetaminophen 10/325 mg PO every six hours as needed. The patient described dysphagia with both solids and liquids following the surgery, and non-specific changes in his voice that that made it *difficult to sing.* Even more concerning to the patient has been urinary incontinence, which he began experiencing immediately following the surgery. He reports multiple episodes of urinary incontinence daily, with increasing frequency of occurrence, and for this reason he has been wearing disposable absorbent undergarments. He also continues to describe left upper extremity paresthesias and gait disturbance.Post-surgical radiographs obtained on August 1st revealed appropriate fusion at the C4-C5 level.The patient describes significant disability following his surgery, worse than after his accident. He has become increasingly reliant on assistance with activities of daily living. He states his activity level has decreased due to his pain and urinary incontinence. He continues to receive chiropractic therapeutic modalities.Prior to his accident, the patient reports that he was very active and in excellent health. He was employed as an operating room technician until his retirement at age 53. He does have a history of type II Diabetes mellitus and hypertension and states that both are well controlled. Prior injuries include a fracture to his left foot approximately seven years ago and a fracture to his right ankle with subsequent open reduction and internal fixation approximately 15 years ago. Downloaded by (-1)

MedPix No: EXAM & LABS Upon physical examination on 28 August, the patient reported neck pain during all ranges of motion of the cervical spine. He reported increasing pain in the left upper extremity during neck flexion and during left lateral bending. The reflexes of the biceps and triceps muscles were determined to be 2/4 bilaterally. Grip strength was tested on the left to 55 pounds and on the right to 65 pounds and the patient is right hand dominant. Romberg testing was within normal limits. Pinch grip was tested at 11 pounds on the left and 12 pounds on the right. The patient was unable to perform the tandem walk, falling to the left side. He had an unsteady gait with a slightly propulsive, slightly plantar-flexed positioning of the ankle as he brought his feet in front of him. During range of motion of the thoracolumbar spine, lower back pain occurred during flexion, left and right lateral bending, and extension. When the straight leg raise was tested on the left side, the patient reported lower back pain that extended down the left lower extremity to the ankle, but mostly from the knee to the ankle. When passive straight leg raise was performed on the right side he reported lower back pain. On muscle strength testing, a weakness of elbow extensors, elbow flexors, and abductors of the left shoulder was noted.Upon monofilament testing, a hypesthesia was noted over the volar aspect of the thumb and index finger on the left side and the volar aspect of the thumb on the right side. A hypesthesia was noted on the dorsal aspect of the thumbs bilaterally. A hypesthesia of both feet on the plantar surfaces, as well as the dorsal surfaces and between the great and second toes was noted.As part of the evaluation, the patient completed the Pain Disability Questionnaire, which was developed to measure the functional status of patients with chronic pain and is primarily intended to ascertain how pain affects disabilities and activities of daily living. He scored 125 out of 150, indicating severe pain disability. The Neck Pain Disability Index Questionnaire was also administered to the patient and he scored 68%, indicating back pain in the cervical range that impedes all aspects of the patients life.

C2-C3: Sagittal RADAR FSE T2-weighted image crosslinked with Axial T2-weighted GRE image. Broad-based posterior bulge/subligamentous protrusion partially effacing the anterior subarachnoid space. Downloaded by (-1)

C3-C4 level: Sagittal RADAR FSE T2-weighted image crosslinked with Axial T2-weighted GRE image. Mild to moderate disc space narrowing with spondylosis and Grade 2 degenerative disc disease changes with broad-based posterior herniation and hypertrophy of the posterior longitudinal ligament. There is impingement on and mild flattening of the ventral spinal cord. Hypertrophy of the uncovertebral joints is present with biforaminal stenoses. Downloaded by (-1)

C4-C5: Sagittal RADAR FSE T2-weighted image crosslinked with axial T2-weighted GRE image Moderate disc space narrowing and spondylosis with anterior spurring, Grade 2 degenerative disc disease changes, and large diffuse posterior herniation of the extrusion type extending approximately 6 mm into the spinal canal with moderate impingement on and flattening of the spinal cord with resulting acquired central spinal stenosis. Hypertrophy of the uncovertebral joints and mild encroachment and narrowing of the foramina. Downloaded by (-1)

C5-C6: Sagittal RADAR FSE T2-weighted image crosslinked with axial T2-weighted GRE image Moderate disc space narrowing and spondylosis with Grade 2 degenerative disc disease changes, posterior ridging, and questionable minimal retrolisthesis with mild diffuse posterior protrusion partially effacing the anterior subarachnoid space without central spinal stenosis. Hypertrophy of the uncovertebral joints and biforaminal stenoses, slightly worse on the left. Downloaded by (-1)

C6-C7: Sagittal RADAR FSE T2-weighted image crosslinked with axial T2-weighted GRE image Moderate disc space narrowing and spondylosis with Grade 2 degenerative disc disease changes, posterior ridging, and bulge with hypertrophy of the posterior longitudinal ligament. There is partial effacement of the anterior subarachnoid space without central spinal stenosis. Hypertrophy of the uncovertebral joints and biforaminal stenoses. Downloaded by (-1)

FINDINGS MRI of the cervical spine was performed. Prominent reversal of cervical lordosis and multiple level spondylosis were noted. Multiple level disc herniations were noted, most severe at the C4-C5 disc level, with prominent flattening of the spinal cord and central spinal stenosis at the C4-C5 disc level. There is hypertrophy of the uncovertebral joints, with encroachment on and narrowing of the foramina at multiple levels, most prominent at the C3-C4, C5-C6, and C6-C7 disc levels.

DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Cervical radiculopathy with myelopathic changes - Transverse myelitis - Viral myelitis - Epidural abscess - Infarction - Subacute combined degeneration - Syringomyelia

Diagnosis: Cervical radiculopathy with myelopathic changes Dx Confirmed by: EMG

DISCUSSION The patient reported pain in the cervical region with radiation to the left upper extremity. Nearly all patients with cervical radiculopathy present with pain in the neck or arms, and this pain may be in the cervical region, the upper limb, the shoulder, or the inter-scapular region. The patient had subjective sensory changes in the left upper extremity and monofilament testing revealed decreased sensory function in the left upper extremity. Paresthesias in the distribution of a nerve root occur in approximately 80% of patients, however, due to overlap of dermatomes, dense, discrete sensory losses are uncommon in lesions of a single root. Muscle strength testing revealed weakness of elbow extensors, elbow flexors, and abductors on the left shoulder. This finding is consistent with myelopathic change, which can result in lower motor neuron deficits at the level of spinal cord involvement. The patient had an unsteady gait with a slightly propulsive, slightly plantar-flexed positioning of the ankle as he brought his feet in front of him. Gait disturbance is common in myelopathy, characterized by a spastic, scissoring quality. The patient also described urinary incontinence. Bladder dysfunction, leading to urgency, frequency, and incontinence, also occurs in approximately 20% of cases of myelopathy. - - In addition to the findings on clinical examination, upper extremity EMG studies revealed left C6 radiculopathy. Electrodiagnostic testing was performed on 30 August. Nerve conduction studies of the upper extremities revealed diffuse/symmetrical sensory and motor peripheral polyneuropathy. These findings are compatible with the patient's history of Diabetes mellitus. Needle EMG examination revealed increased insertional activity coupled with spontaneous potentials isolated in the left biceps brachii, left brachioradialis, and left cervical paraspinal muscles. The right upper extremity and right cervical paraspinal needle EMG examination was unremarkable. These EMG findings are indicative of an active/acute left C6 radiculopathy. Thus, the EMG confirmed the diagnosis of cervical radiculopathy. The presence of myelopathic changes is confirmed by the clinical findings, particularly the patient's upper extremity weakness and paresthesias, gait instability, and urinary incontinence. - - Although the patient's worsening radiculopathic and myelopathic symptoms are related temporally to his discectomy and spinal fusion surgery, the causal relationship between the surgery and the exacerbation of symptoms is uncertain.