Case; Bilateral paresthesia upper and lower limb

[squizzyhunter]

Hi there guys
Here is a case Im having some issues with


PC = Bilateral shoulder pain (R++) with associated pain at sternoclavicular joint and bilateral peri scapula
Onset - approx. 10yrs, from someone falling on top of him while lateral recumbent – couldn't move for 3/7
Pain getting worse
Pain = Sharp 8/10
Bilateral P&N arms and hands
Numbness in both thumbs and forearms
Headaches
PC add= Bilateral P&N in legs and numbness in large toes
Had visited GP after initial trauma= Analgesics, NASAD's, imaging chest and shoulders NAD
Chronic Alcoholism from age 16-36 (Approx. 2-3L of fortified wine per day)
Chronic Cannabis use from age 16-36 (up to 3g per day)
Smoker from age 18-37 (15-20 per day)
No alcohol or drug use for last 3.5 yrs.
Has Hypertension Dx and is taking Avapro
Has been prescribed analgesics which he uses when pain is severe
DDx
Have been
Alcoholic Polyneuropathy = Bilateral P&N arms & legs, numbness, Chronic Alcoholism
Diabetic Polyneuropathy= Bilateral P&N arms & legs, numbness, prevalent in family
Space occupying leision METS or (osteochondroma)
Cx Central disk protrusion
Ms -ve = Male, age

Now have Cx CT
There are significant posterior disk prolapses at C6 + 7
Now thinking C6 Disk in conjunction with Lx disk (has low back pain but NAD in clinical provocation)
Or possible METS

The Patient lives 7 hours away on a indigenous reserve and I cant see him for a month and he has no access to further imaging until then.

Any thoughts as it's the the Occam's razor Vs Hickam's dictum debate
Cheers

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[squizzyhunter]

Ps forgot to add
+ve spurlings, +ve Cx distraction and +ve Valsalva
Lx SLR = Had pain 20 sec later at L4

 

[squizzyhunter]

More on Phys exam

Phys exam
Painful arc = Loud clicking and crepitice R AC
Hawkins Kennedy - +ve Empty can = -ve
R SC joint inferior w crepitice
Cx = restricted SB L & R C4/5/6
Able to reproduce pain via palp at C5/6
R short leg, R ASIS inferior = Anatomical?
SLR = -ve
Referral from R rhomboid to SC and AC
Reflexes = L/L ++, U/L ++, Umbilicus ++
Dermatomes = NAD
Vibration sense = NAD
Myotomes = Lower limb 5, Upper limb 5
Cranial nerve exam = NAD
Romberg's -ve
Pronator drift –ve
Positional sense = NAD
Nerve tension tests = +ve R Median N
Spurlings = +ve
Distraction = +ve
Valsalva = +ve
Lhermitte's sign = -ve
Lx SLR= Pain at L4 after 20 seconds

 

[AlternateSome1]

I can't comprehend what most of this means. Can you write in prose and get rid of the short-hand?

 

[neurodoc]

I can't comprehend what most of this means. Can you write in prose and get rid of the short-hand?

Like you, I'm not sure what's going on. It seems that the patient has symptoms (paresthesiae) in both the lower extremities and the upper extremities. It could be a cervical problem. You need to apply the "neurological method" of diagnosis. A cervical lesion can affect both the cervical sensorimotor nerve roots and the sensorimotor "long tracts" passing through the cervical cord.

 

[squizzyhunter]

Hi guys yes spelling have never been one of greatest attributes
Long storey short
The guy has bilateral paraesthesia of upper and lower limbs
Has all the clinical signs of Cervical disk protrusion and has been confirmed on CT, yet I'm not sold on that it is causing the Lower limb paraesthesia ant numbness. On the straight Leg Raise (SLR) he only gets pain 20 seconds later localised to L4 with no radicular reproduction. Can't get him back for further imaging of the lower back for a while but just can't get it out of my head.

How commonly do you see a cervical lesion impacting the tracts to the lower limb and wouldn't you expect physical exam nerve tension tests to be through the roof while testing the lower extremities?

 

[95439]

Definitely sounds like a cervical cord issue. Needs an MRI of the C-Spine with and without contrast. r/o syringomyelia or brown sequard syndrome. Likely is a herniated disc involved. See alot of patients with lower extremity issues with cervical cord problems. It all passes thru there.

 

[AlternateSome1]

Agreed. Sounds like a cervical cord lesion.

 

[neurodoc]

OK, you've got a CT showing disk bulges...get the MRI to see if the cord is compromised. I still can't figure out from your exam whether or not the LE's are affected by cord compression at the cervical levels. The patient could also have polyneuropathy (many possible causes for that). For all I know his UE symptoms could be due to carpal tunnel syndrome as well. MS is still in the differential, in which case a brain MRI might be helpful.

The two most useful additional studies (besides a better documented neuro exam), would IMHO be brain and C-spine MRI and EMG/NCS of the upper and lower extremities.

 

[Mattchiavelli]

How did someone fall on this person? Is this patient carrying people or participating in crazy crap where people can fall on you like rodeo or similar? Why hasn't diabetes been checked for or what's the A1c status?

I have to give OP credit because with the font change when you try to quote it gets even more difficult to read, so here it is oldschool

"Loud clicking and crepitice R AC"
I realize I'm just an intern but doesn't this denote at least something musculoskeletal is going on, because I've never known of anything neurological that makes you go "click"

Idk I don't see a lot going on with this guy neurologically on physical, and a lot of good historical stuff is absent