A-19 Clinical Case Slide - Chronic Conditions I: MAY 30, 2007 9:30 AM - 10:50 AM ROOM: 341
HISTROTY: 73-year-old, right-handed retired male golfer, seen in family medicine clinic to evaluate rapidly progressive generalized weakness one day after an ED visit with discharge diagnosis of “generalized weakness, unknown etiology”. He denied any constitutional, EENT, CR, GI, or cauda equina symptoms. He c/o progressive numbness, tingling, and weakness in both upper extremities. He admitted to a great deal of stress caring for a demented spouse.
Past medical HISTROTY: Hypertension, remote colon cancer, s/p resection and right-sided carpal tunnel surgery one month prior. Meds: Spironolactone and Celebrex.
PHYSICAL EXAMINATION: Admitted in a wheelchair and needed assist to the exam table. Gait: broad based and ataxic. BP 165/67, respirations 20, pulse 73, O2 saturation 96%. Alert, oriented x 3, no MMSE deficits. Neck range of motion diminished, weakly positive Tinel sign, negative Phalen, negative carpal tunnel compression. Negative Spurling's & Lhermitte's. Hyperreflexia is noted in lower extremities with sustained clonus & Babinski's sign positive bilaterally. Motor: symmetric quadriparesis. PE: n1.
Generalized Weakness and Deconditioning (medical)
Bilateral Carpal Tunnel Syndrome
Cervical Spinal Canal Stenosis
Cervical Myelopathy Progressive Quadriparesis
Normal Pressure Hydrocephalus
TEST AND RESULTS:
EMG done prior to CTS surgery: median neuropathy at the wrist bilaterally.
Comprehensive lab panel: normal
Head CT scan in ED: consistent with age, no focal abnormalities.
Cervical spine: Anterolisthesis of C3 on C4 and C4 on C5 with neural foraminal stenosis, multiple levels.
M. R. cervical spine: Severe central canal stenosis at C3-C4 due to broad based disk herniation & anterior sub luxation of C3 on 4. Disk material encroaches upon the cervical cord at this level.
FINAL WORKING DIAGNOSIS: Severe cervical spinal canal stenosis, C3-C4 level with progressive cervical myelopathy.
TREATMENT AND OUTCOMES: Cervical decompressive laminectomy C-3, C-4, segments, posterior, cervical instrumentation, with lateral mass fixation C2-C5, lateral fusion graft: C2-C5. He has residual paresthesias; but enjoying golfing again!