Spinal Cord Compression Presenting with Neck Pain for One Month

Author: V. Dimov, M.D.
Reviewer: . S. Randhawa, M.D.

A 54-year-old African American female (AAF) is admitted to the hospital with chief complaint (CC) of neck pain for one month. The pain is at the back of the neck, described as excruciating in character, 10/10 on a 0-10 scale, temporarily relieved by pain medications, exacerbated by movement, and radiating down the left arm. The pain is associated with left arm numbness which is not confirmed by physical exam. She has never had similar symptoms before. The patient has no fever, chills or photophobia.

Past medical history (PMH)

End-stage renal disease on hemodialysis (ESRD on HD), chronic obstructive pulmonary disease (COPD), hepatitis C (HCV), hepatitis B (HBV), cocaine abuse, alcohol abuse (EtOH abuse), smoking.

Past surgical history (PSH)

Left lower extremity gunshot wound (LLE GSW), chest stabbing.

Physical examination

No neurological deficits.
Limited range of motion (ROM) in the neck but no true neck rigidity.
Local tenderness at the back of the neck.
Right upper arm arteriovenous fistula (AVF) with good bruit and pulse.

What is the most likely diagnosis?

An MRI was done in the ER and showed a severe spinal canal stenosis with cord compression in the C3-C7 region with spinal cord edema.


Cervical Spinal Canal Stenosis (click to enlarge the images).


MRI report (click to enlarge the images).

What therapeutic approach would you suggest?

Dexamethasone (DXM) 18 mg IV x 1 was given initially, and then DXM 6 mg IV q 6 hr. An urgent neurosurgical consult was requested.

What happened?

The patient was admitted to the hospital and she had a cervical spinal block with injection of DXM in the spinal space. The pain improved. No neurological deficit was detected.

The neurosurgeon evaluated the patient and scheduled a cord decompression.

References

Dermatome Images in Netter Atlas.
Diagrams of Neurons, Synapses, Neuroanatomy, and Endocrinology.
Paresthesias: A Practical Diagnostic Approach. AFP.
Clinical Approach to Neck Pain.

Published: 03/2005
Updated: 05/19/2007

8 comments:

  1. I hope for the, sake of the patient and all the physicians involved in this case, that she didn't fall or become involved in a rear end collision between the time of discharge from the ER and the time she saw the neurosurgeon. If a traumatic transverse myelitis were to occur, not only would the patient be devastated, but I doubt if there would be any defense if a malpractice suit were to be filed. I would have expected a rather urgent surgical decompression to have been accomplished. The dilemma would be whether to do a three level anterior decompression or a posterior one.

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  2. From a neurological standpoint this patient does have cervical spondylosis but there is no clinical evidence of a myeolopathy (cord compression). Hence she did indeed require a neurosurgical evaluation but the use of steroids was questionable. To practice defensive medicine this patient should have been admitted to the hospital and an urgent neurosugical evaluation sought.

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  3. could you not create a page showing what all the abbreviations stand for?its like reading a foreign language!and yes i am a doctor but not in the US!

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  4. The abbreviations are used on purpose to make the clinical cases as authentic as possible. Whether we like it or not, part of the reality of the American health system is the widespread use of abbreviations. Click here for a Complete List of Medical Abbreviations and Acronyms on Wikipedia.

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  5. Due to the severity of her canal stenosis, and radicular symptoms she will require an anterior 3 level corpectomy and fusion, along with a posterior laminoplasty as well, to maintain cervical spine stability, as this may progress. Any acute trauma would cause a quadrplegia with pooor prognosis so an immediate neurosurgical consult, a philadelphia collar to be used as well. Steroids are of no known benefit except in acute cord injury where methylprednisolone would be ideal if the patient reaches a hospital care setting on time.

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  6. You never said that she had any neurological deficit.I did not know what is the indication of decompression. You talked about neck pain and radicular pain but never the myelopathy sign such as spasticity,hyper reflexia,difficulties in using the hand and walking.
    If there is myelopathy,the decompression is indeed.
    If only radiculopathy present one months we can use physical therapy and drugs.
    You made a lot of confusion especially for the medical student.

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  7. I think the only important recomendation to this patient is that she must be very careful about any traumatic event to her cervical spine such as wiplash injury .even mild injury may lead to centeral cord syndrome in this patient.prophylactic surgery is not indicated in this patient without any sign of myelopathy if there is only radiculopathy, after a course of conservative treatment surgery must address only to the site of pathology.neck pain in this patiet doesn,t have any surgical solution

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  8. dr uttam bhatta12/21/2009 9:13 AM

    thanks for the case
    uttam bhatta

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