This topic contains 3 replies, has 1 voice, and was last updated by James Phipps February 25, 2019 at 12:49 pm.
February 22, 2019 at 5:48 pm #4682
The below case is our neck specialist, Dr. Joe’s.
1st Order Hx Points:
- Age: 37
- Sex: M
- a) C5-C7 Neck Pain bilateral
- b) Hands bilateral (thumb, index, middle fingers) occasional pinky and ring fingers
- a) sharp/stabbing/achy
- b) numbness, pins & needles
- I: worst 10+/10 rest 3/10
- P+: All activity (standing 10 mins, shower, driving, sitting) – provokes both locations
- P-: R/X and reclining
- C6, C7 disc, SOL, affecting bilateral NR @ foramen
2nd Order Hx Points:
S/X since MVA accident on 10/8/16, currently on disability
MRI DOE: 1/23/2017
C5/6 moderate post. disc osteophyte complex noted causing mass effect on the anterior thecal sac and mild spinal canal narrowing. Spinal cord demonstrates faced joint arthropathy and mild uncovertebral arthropathy. There is no significant neural foraminal narrowing.
C6/7 No disc herniation is seen. Mild facet joint arthropathy is seen. Uncovertebral joints are grossly unremarkable. No spinal canal or neural foraminal narrowing is seen.
Exam: –> Tomorrow
February 24, 2019 at 12:36 pm #4684
- I’m not familiar with the mechanics of disc pathology. Can the bolded results above cause 2 levels of dermatomal symptoms, bilaterally? If the mass effect is causing the symptoms, why isn’t the C8 NR affected too?
- Has anyone seen C7 s/x when they have clean C7 MRI?
Adam Holen D.C.
If the osteophyte complex is causing spinal canal narrowing, it can affect the segments below with NR symptoms. The ‘occasional’ pinky and ring finger symptoms would indicate C8 involvement. Definitely get eyes on the film (if you haven’t). To be 37 and have moderate osteophyte complex following trauma with “no significant” NF narrowing or notable issues with the discs seems unlikely, but either way, he has massively reduced capacity.
Is the “C5-C7 neck pain bilateral” at those levels or referral patterns into the traps and shoulder blades? What does he do for work/what’s the load on his neck? Has his 10/10 been since the MVA or has it gotten progressively worse? The anterior thecal sac mass, osteophyte complex, and facet joint arthropathy explain a lot, but I’d want to make sure the discs are accounted for.February 25, 2019 at 12:38 pm #4685
Keith Puri, DCParticipant
A few things to consider –
1. This MRI is 2 years old and it’s likely these findings have degenerated further.
2. I do not have a reference but I would believe its less likely to have disc pathology significant enough to cause bilateral exiting NR compression or bilateral foraminal stenosis in a 37-year-old and more likely to have compression within the bilateral traversing nerve roots or thecal sac. The MRI did show C5/6 moderate post. disc osteophyte complex causing mass effect on the anterior thecal sac and mild spinal canal narrowing. So, it’s possible this finding could create pain, numbness or tingling within the right and left C6, and C7 dermatomes. I do not believe mild spinal canal narrowing at C5/6 is capable of producing bilateral C8 dermatomal symptoms.
3. Has this case been through the medical-legal process? If so, there is likely a biopsychosocial component that needs to be considered or addressed given his ongoing disability and 10+/10 pain score. No one in an ID office should ever have a pain score of 10+/10. That finding alone screams biopsychosocial involvement. The “All activity (standing 10 mins, shower, driving, sitting) – provokes both locations” just reinforces it.
Sounds like a challenging case. Good luck!February 25, 2019 at 12:49 pm #4686
My understanding is that mass affect just means is pressing on the thecal sac and doesn’t mean its compressing anything unless there is mention of cord compression or foraminal narrowing. So I don’t think the C5/6 disc is going to be creating whole hand symptoms bilaterally according to the 2017 MRI report.
Since his provocative/palliative positions are pointing to a cervical origin in addition to the cervical exam I would examine the nerve roots at the scalenes since that can create bilateral whole hand symptoms and tends to get really jacked up after MVA. Bakody, max cervical compression test will also help you with the diagnosis.
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