Unusual "polyradiculopathy"

[RUOkie]

I saw a woman in my office today which was a very interesting case. She is a 45y/o ER nurse, and when she was a teenager, had a oropharyngeal cancer which was treated with XRT (for those of you young-un's that is cobalt beam XRT) to the head and neck. She was treated for cure.

5 years ago she began to have intermittent neck pain, and when I saw her 4 weeks ago, had significant atrophy of the posterior strap muscles of the neck, atrophy of the SCM, Trapezius, and obviously a marked head forward position.

EMG showed widespread, small fibs and PSW most concentrated in the SCM, Traps, and scalenes,but also in the limb muscles of both arms. Myokymia was present electrically in a patchy distribution (but no visible myokymia on PE).

I did an MRI (a 3T magnet) which only showed MILD DDD worst at C6 and C7, but widely patent neuroforamina and no central stenosis. There was no myelomalacia.

She is not interested in medications, so I am just sending her to PT for a progressive strengthening and stretching program and scapular stabilization (as possible). What else would you guys/gals do?

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[SSdoc33]

I saw a woman in my office today which was a very interesting case. She is a 45y/o ER nurse, and when she was a teenager, had a oropharyngeal cancer which was treated with XRT (for those of you young-un's that is cobalt beam XRT) to the head and neck. She was treated for cure.

5 years ago she began to have intermittent neck pain, and when I saw her 4 weeks ago, had significant atrophy of the posterior strap muscles of the neck, atrophy of the SCM, Trapezius, and obviously a marked head forward position.

EMG showed widespread, small fibs and PSW most concentrated in the SCM, Traps, and scalenes,but also in the limb muscles of both arms. Myokymia was present electrically in a patchy distribution (but no visible myokymia on PE).



I did an MRI (a 3T magnet) which only showed MILD DDD worst at C6 and C7, but widely patent neuroforamina and no central stenosis. There was no myelomalacia.

She is not interested in medications, so I am just sending her to PT for a progressive strengthening and stretching program and scapular stabilization (as possible). What else would you guys/gals do?

oooooohhhh, myokymia. im jealous. im serious, btw.

 

[RUOkie]

oooooohhhh, myokymia. im jealous. im serious, btw.

One of my steady referral sources is an oncologist. I actually see myokymia one or two times/yr. We have some very agressive radiation oncologists around here

 

[PMR 4 MSK]

I'd treat the same way.

 

[Ludicolo]

I’ll presume limb SNAPs in this patient were normal, if you’re calling it a polyradic. Were there any MUP changes on needle exam? Often I see small, myopathic MUPs in the paraspinals in these patients, sometimes with decreased insertional activity, more consistent with a focal fibrotic/myopathic type picture. A form of the so-called “dropped-head” syndrome. But I’ve also seen both the focal cervical myopathy and the limb radiculoplexopathy co-exist.

Since this is radiation induced, it will slowly progress, so patient education is key. The exercise program (emphasis on posture and scapular retraction) can help preserve function to a certain extent. I’ve tried to accommodate for severe loss of extension in some of these patients w/ various cervical collars, but the degree of muscle atrophy often makes orthotic fit uncomfortable.

Other medical considerations: make sure she’s endocrinologically stable. Her thyroid/parathyroids were likely affected by the XRT, and down the road she’ll have to worry about things like osteoporosis and its associated stuff. Pulmonary fibrosis and cardiomyopathy are also things to look out for.

 

[RUOkie]

I'll presume limb SNAPs in this patient were normal, if you're calling it a polyradic. Were there any MUP changes on needle exam? Often I see small, myopathic MUPs in the paraspinals in these patients, sometimes with decreased insertional activity, more consistent with a focal fibrotic/myopathic type picture. A form of the so-called "dropped-head" syndrome. But I've also seen both the focal cervical myopathy and the limb radiculoplexopathy co-exist.

Since this is radiation induced, it will slowly progress, so patient education is key. The exercise program (emphasis on posture and scapular retraction) can help preserve function to a certain extent. I've tried to accommodate for severe loss of extension in some of these patients w/ various cervical collars, but the degree of muscle atrophy often makes orthotic fit uncomfortable.

Other medical considerations: make sure she's endocrinologically stable. Her thyroid/parathyroids were likely affected by the XRT, and down the road she'll have to worry about things like osteoporosis and its associated stuff. Pulmonary fibrosis and cardiomyopathy are also things to look out for.

This lady continues to be followed by Shriners as part of a study. They keep a ridiculously close eye on endocrine issues (she is on thyrod replacement and takes Vit D weekly). She gets DEXA's yearly. --Very good points to bring up though!

Her weakness is not so profound that she has a true "dropped head", but was certainly going in that direction. Orthoses would be out at this point more for cosmetic reasons, as well as its just not that bad yet.

What I found most interesting, is that this started worsening 25 years after her XRT! (at least per her report-I suspect that she has had some problems all along) Most of the longitudinal studies say that things worsen 5-10 years post XRT.

Oh and yes the Sensories were normal.