21 y/o female cervical spine

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bones2000

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Case has me worried, came into our office today.

21 y/0 female previous MVA 2015
c4-6 ACDF 8 months ago

Complaints of not getting better, weakness in legs, difficult balancing, positive clonus, positive babskin, positive hyperflexia, positive Lhermitte.
She says she can't feel where her feet are when she walks and she feels "drunk". Trouble swallowing, trouble breathing, feet are numb, hands are numb.

New MRI report shows the radiologist found no herniations and no stenosis and her cervical spine is in great shape. AP canal diameter from c2 all the way down to c7 is 9 or 8 mm it states.

Any help? Hydrocodone, Steriod, Flexiril is not working for her she says.
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What is your relation to the patient?

Please give more information on preoperative, postoperative exam findings and any changes in her symptoms.

Why did she receive surgery and what were her symptoms prior to surgery?
 
SpineBound said:
What is your relation to the patient?

Please give more information on preoperative, postoperative exam findings and any changes in her symptoms.

Why did she receive surgery and what were her symptoms prior to surgery?
Click to expand...



This patient has me worried because I know her family personally (older siblings classmates). Has been coming to the practice for years for general health (internal medicine)


Good health before being rear ended at 40mph. A little overweight but no diabetes, no smoking.

Preoperative MRI: AP Canal 10mm. Spinal stenosis, central disc herniations c4-6 cord compression >40% both levels. She could not walk because her balance was so severely off, she kept tripping over her own feet, could not put heel to heel.

Immediate post operative I got a copy of surgeons notes: Patients canal is much tighter than expected. Neural components were compressed. Can walk but not for long, gets electrical type pain through the arms and legs still. X-RAY of fusion looks good.

Completely fused by 3 months but symptoms progressing downhill, came into the office saying she is experience pain 8/10. She stated if feels like her neck is being "rug burned" and constantly pinching. I prescribe gabapentin. She could stand but for no longer than 5 minutes.

Fast forward: 3 months later (6 months after fusion) she asks me to get her an MRI order because the neurosurgeon retired 5 months after she had surgery because of vision problems. Of course said yes given the history. Newest most alarming symptoms are temperature sensation loss in arms and legs and decreasing in her gait ability.

She got the MRI finally 3 weeks ago and I saw her today for follow up. I just don't know what to do. I am thinking about sending her to Duke or Wake Forest.
 
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DNC. Does not compute.
MRI brain, entire spine, ct myelogram C-spine. Emg/ncv with pmr doc.

Symptoms wildly discordant from imaging.
 
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All done pre surgery lobelsteve. Patient had full spinal MRI, BRAIN MRI. Nothing there other than neck of course. I will send for CT scan of brain as I don't think her insurance will pay again but I will try. I sent her 3 months ago had ECHO of heart because of shortness of breath.

What are the 'normal' diameter for cervical spinal canal? That is the only thing that's changed. She went from 10mm to 9/8mm.

Thanks for all your help guys.
 
bones2000 said:
Case has me worried, came into our office today.

21 y/0 female previous MVA 2015
c4-6 ACDF 8 months ago

Complaints of not getting better, weakness in legs, difficult balancing, positive clonus, positive babskin, positive hyperflexia, positive Lhermitte.
She says she can't feel where her feet are when she walks and she feels "drunk". Trouble swallowing, trouble breathing, feet are numb, hands are numb.

New MRI report shows the radiologist found no herniations and no stenosis and her cervical spine is in great shape. AP canal diameter from c2 all the way down to c7 is 9 or 8 mm it states.

Any help? Hydrocodone, Steriod, Flexiril is not working for her she says.
Click to expand...
Neurology consult. Doesn't sound anatomic to me. But probably need a myelogram to determine. I've seen huge stuff show up on myelogram that wasn't on an MRI.
 
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bones2000 said:
All done pre surgery lobelsteve. Patient had full spinal MRI, BRAIN MRI. Nothing there other than neck of course. I will send for CT scan of brain as I don't think her insurance will pay again but I will try. I sent her 3 months ago had ECHO of heart because of shortness of breath.

What are the 'normal' diameter for cervical spinal canal? That is the only thing that's changed. She went from 10mm to 9/8mm.

Thanks for all your help guys.
Click to expand...

Normal is 11mm and up, but plenty of 6-7mm cervical canals out there with no symptoms. 8mm is uninteresting.
 
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Strange case. I would order a CT myelogram and a repeat MRI of the brain. If this is unremarkable, the patient needs a neurology consult and a full workup. Weird case. Keep us posted on how the workup pans out. Some things are worrisome for ALS but the sensory findings wouldn't fit with this diagnosis. Maybe a severe case of MS?
 
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this is precisely what neurologists are for. and regional medical centers.
 
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Ligament said:
Neurology consult for sure. Symptoms are textbook badness.
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Or someone reading up on such badness?

Id suspect central (CNS) or really central (ie psychosomatic). Hard to believe swallow issues are cervical spine (swallow is cranial nerve, after all...)


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Ducttape said:
Or someone reading up on such badness?

Id suspect central (CNS) or really central (ie psychosomatic). Hard to believe swallow issues are cervical spine (swallow is cranial nerve, after all...)


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Click to expand...

I do agree with you. Either its real badness to totally fake badness. I don't think it will be anything in between.
 
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Absolutely neuro consult now. Would consider repeat MRI brain with contrast and cervical ct myelo, but also reasonable to defer to neuro. Also need to look at c spine MRI yourself, not report. Diameter doesn't mean that much. You see any csf left around cord, physical compression, cord signal change, syrinx? In the end may turn out to be nothing but progressive myelomalacia from prior cord compression pre-op....but can't take that chance without full workup


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1) UDS with GC/MS.
2) UE and LE EMGs from a trusted physician, possible myelogram and definite Neurology consult.
3) Reconsult/ re-evaluation with ortho/spine surgery - you want her to establish care with one and get their recommendations sooner than later.
4) Frequent follow ups by you to see any changes in clinical condition. The diameter by itself is not too concerning at 8 mm...but again, MRI by itself is not diagnostic of anything and clinical findings trump imaging results.
 
Ligament said:
I do agree with you. Either its real badness to totally fake badness. I don't think it will be anything in between.
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"positive clonus, positive babskin, positive hyperflexia, " - i think two of those can be faked, but not all three.
 
Ligament said:
If I can fake those, why can't she? I agree you'd have to be skilled to fake...but it is possible..
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I don't think this is the case at all, poor parents are worried sick. I don't see her doing this to be fake. Serious symptoms, missing work as a elementary teacher. I will send her to all your suggestions.
 
OK i have been practicing and now i can fake a babinski .
 
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Some thing doesn't fit here.

If she is legit then considerations are transverse myelitis, MS, and therapeutic misadventure (the surgeon screwed up). I would also throw ALS in the mix; it is rarely associated with sensory symptoms.

Would get a new EMG and myelogram.
 
I'm just curious: If you're physiatry-trained, what do you think that a neurology consult will add to the case? I'm not dissing my neurology colleagues, but my neuro exam is just as good as theirs it. Unless it's seizures, NMJ, paraneoplastic, MS, stroke, or secondary headaches, I don't see what they have to add to the situation...
 
After getting a copy of the MRI, to me it looks like one of the discs is hitting the spinal cord from the front. It looks pretty good size to me but there's fluid behind the cord at that level but none in front. It looks like the cord is deformed at that level. I am no expert at these.
 
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5mm CSF behind the cord, cord not being displaced posteriorly.
Meh. But it is just a single pic. Would want T1/T2 sag and axial cuts from C3-4 to C6-7.
And ability to cross-localize.
 
I will post here soon. I have copy of her MRI post operative (I did not know this was done) she said it was a CT scan and 11/30.
 
MRI august one month post fusion
 

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She also needs some flex/ext films. You really want to rule out some instability with the weird things she is describing.
 
epidural man said:
Neurology consult. Doesn't sound anatomic to me. But probably need a myelogram to determine. I've seen huge stuff show up on myelogram that wasn't on an MRI.
Click to expand...
Like what?
When do u decide to order a myelogram?
With above type symptoms and an MRI that does not explain?

I have mostly only seen spine surgeons order. Also some serious morbidity can result...so I always hesitate.
 
Timeoutofmind said:
Like what?
When do u decide to order a myelogram?
With above type symptoms and an MRI that does not explain?

I have mostly only seen spine surgeons order. Also some serious morbidity can result...so I always hesitate.
Click to expand...

large chunks of disc that for some reason didn't show up in MRI. I wouldn't order - I would sent to neurology and let them decide if they need to order.
 
I'd add an expanding syrinx in that differential...

Regardless, I'd get a NSGY and neurology consult in at the same time there to an academic center of choice with the realization that they'll probably be booked 3 months out...
 
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