Tuesday, June 7, 2016

Hi Everyone,

I've had a lot of crazy things happen recently (moving to a new place, dropping my laptop and breaking it, and I've been working hours like crazy). So, to apologize for my absence, I'm going to try to add lots of things to the blog today so that I can share some of the interesting things that I've been seeing here. Here's a small case report that I wrote up for my patient as I followed a very unique presentation:

Case Report:

Patient presented with history of cervical spine pain and Guillain-Barre syndrome. But in the last two months he has been having spasms that he feels in the upper thoracic spine and also in the chest. He has the feeling as if he may not be able to breathe (but he is able to keep breathing). Starts in the back, then squeezes at the chest, and then for some time it proceeds for 2-10 minutes. The first time it happened he was drinking a glass of water and it occurred when he bent forward a bit. Patient walks 4-5km per day and it can also happen during this time. Has stopped doing hard sports for the time being, used to be a big tennis player.

Physical Exam found upper extremity reflexes to be 2/5 bilaterally with no sensation loss. Lower extremity reflexes were found at 3-4+/5 bilaterally with no sensation loss bilaterally. S1 reflex on both sides had one beat of clonus and striking the right patellar reflex was sometimes able to produce a strong response in the opposite leg. Cervical ROM was not limited or provocative for any significant pain. When palpating the upper/mid thoracic spine that patient felt a sensation of heightened "pressure". Cervical flexion and cervical slump test reproduced pain in the upper thoracic spine.

At this time an MRI of the Dorsolumbar Spine was ordered in order to rule out space occupying lesion as a cause of the Upper Motor Neuron lesion symptoms demonstrated in the lower extremity; no cervical MRI was ordered due to the lack of upper extremity/cervical symptoms.

Patient has been worse with walking and sleeping. Cannot sleep on the left side, as soon as he moves his shoulders together the pain increases. Forward flexion is very difficult. Sleeping on the back is the best position. Notices pain in the lower neck. The problem seems to be related to forward flexion movements now, especially with the neck.

MRI of the Thoracolumbar spine shows no evidence of spinal cord compression or cause of myelopathy.

Physical exam now finds DTR 1/5 right bicep with sensory loss on the right C6/C7/C8 dermatomes. DTRs are 4/5 bilaterally in the lower extremity and these reflexes are increased with forward head flexion and decreased with extension of the neck. C7 spinous is extremely painful to palpation.
MRI of the Cervical Spine ordered at this time to determine the cause of the appearance of upper extremity Lower Motor Neuron lesion signs.

Patient returned with the results of the Cervical MRI. Has found that extending his neck during his episodes of spasm reduces the duration of them and he has had less spasms since he has started performing this movement. Patient admits to chronically "cracking" his own neck for the past few years.

MRI of the Cervical Spine finds osteo discal bars at the C3/4, C4/5, and C5/6 levels which are irritating the thecal sac.

Physical exam finds DTR 1/5 right bicep, sensation loss C6/C7 on the right, and DTR lower extremity 4+/5 that is reduced to 2/5 after 10x3 seated extension+retraction movements of the neck.
Due to the signs diminishing with movements in the extension and retraction motions, end of the table distraction coupled with extension and chin retraction was performed in three sets of ten. During this the patient had some discomfort at the cervicothoracic junction but afterwards there was no pain. Patient was instructed on how to perform seated extension and retraction exercises in order to monitor his symptoms and to call if there was any significant change.

At this point the diagnosis of Cervical Spondylosis with Myelopathy/Myelopathic signs was made. It is possible that the patient's chronic self-manipulation of the cervical spine could have contributed to the problem by creating an instability in the cervical spinal ligaments. This instability coupled with the osteo discal bars irritating the anterior thecal sac seem to be the cause of the motor neuron lesion signs that appeared during the examinations. It is also to remember this patient's history of neurologic disease. The patient is set to review again at the week's end on whether the symptoms change with the correctional exercise prescribed today. Patient was informed that if the symptoms do not reduce with corrective exercise that a surgical consultation may be necessary.

After last treatment patient felt okay for two days, then Wednesday was very sore and had some trouble. On Thursday he had no trouble at all even with lots of driving, moving, etc (only a bit of tension at the CT junction). Today he had some trouble in the morning but from 9:00am to 1:30pm there has been no issue. Consulted with the neurosurgeon and the neurosurgeon did not feel that the case was a surgical one. Patient is now able to sleep on his side. When he wakes up is when the pain is most important, but as soon as he returns to laying on his back the symptoms are relieved.

DTR 1/5 right bicep, sensation loss C6/C7 that recovers after allowing the head to stay in extension for about 30 seconds. DTR lower extremity 4/5 right more so than left that recovers to 2/5 after extension movement.

Advised the patient to continue with the extension movement as it both shows promise for his symptoms in the physical exam and he feels relief when performing this action. Patient recommended to seek consultation with neurologist at this time to comanage the case.

1 comment:

  1. Does anyone in the comments have information on Spondylosis? I love reading about back conditions and learning more about what causes them. Another one that I don’t see much written on is lumbar radiculopathy, so if anyone knows where to direct me for treatments related to Cervical Fusion or a herniated disc, let me know!