MedPix Medical Image Database

COW - Case of the WeekCase Contributor: Kristen HongAffiliation: SUNY at Buffalo

MedPix No: 14123 - HistoryPt Demographics: Age = 57 y.o. Gender = womanPt is a 57yo female involved in a MVA 5months ago. As she was departing from a taxi, her coat got stuck in the car door, and was subsequently dragged down the street by the car. The taxi was stopped after traveling two blocks, and though she was bleeding, she was brought home without incident. She presented to the ED the following day where she was examined and radiographs performed. No fractures were detected at the time and she was prescribed pain medication.She denies any other accidents, slips, falls, or injuries affecting her neck or back in the recent past. She does report a previous MVA two years prior in which she fractured her ribs, pelvis, and back, and another accident a year earlier in which she suffered an ankle injury that required surgery. She further reports job-related chronic knee pain. Her review of systems is negative. Other surgeries include a total knee replacement (right) and a tubal ligation 34years ago. Her past medical history is significant for asthma, diabetes, and hypertension; medications include albuterol, metformin, Altase, glucophage, metoprolol, lortab 10s, and Soma. Pt reports that since the accident five months ago, she has been suffering from pain in her pelvis and headaches. She localizes the headaches to the frontal, temporal, and occipital regions. She reports bilateral knee pain, greater on the right, and lower back pain (10/10) and neck pain (9/10). She further reports some loss of bowel and bladder control which she suffered from prior to the most recent accident.

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MedPix No: 14123 - EXAM & LABS56 240lbs 116/76bpCervical Spine, Active ROM: flexion 45/50, Right rotation 60/80, left rotation 60/80, left lateral bending to 20/45, right lateral bending to 30/45, extension 30/60. Pain from neck to left shoulder reported with left lateral bending, right lateral bending, and extension. Right neck pain with left rotation.Bicep/Tricep reflexes 2/4 bilaterally. Cervical distraction unremarkable. Cervical compression produced neck pain from neck to left shoulder and temples. Shoulder elevation 160 bilaterally.Muscle strength: weakness of right bicep, right tricep, and left shoulder external rotators noted at 4/5.Grip strength (Jamar dynamometer): Right hand 30lbs, Left hand 25lbs. Right hand dominant.Hypomobility of the mid cervical region, tenderness to deep palpation in the posterior cervical region. Postural evaluation: Low right shoulder, low left hip. Thoracolumbar ROM grossly limited due to back pain and discomfort. Achilles reflex 0/4 bilaterally. Unable to rise onto her heels due to extreme pain on the left and weakness in the left lower back. She was able to arise onto her toes in the static position. Figure four procedure produced right hip pain when performed on the right. Muscle strengths of the flexor and extensor hallucess revealed a weakness of the right extensor hallucis 4/5. Left stratight leg raise performed to 30 with lower back and left lower extremeity pain. Right straight leg raise on the right perforemed to 40 with lower back and riht lower extremity pain extending to the foot. Pain to percussion and compression of the cervicothoractic spine. Hypomobility and muscle spasm of the cervicothoracic and lumbosacral regions are noted. Neers and Hawkins Kennedy procedure were negative bilaterally. Supraspinatus test positive (left), negative (right). Scar on left ankle from previous surgery.RIGHT SHOULDER ABDUCTION DEFICIT: 9.6%NECK DISABILITY INDEX: 34

T2 FSE: Neural sleeve cyst, C3-4, right.

Neural sleeve cyst evident at neural foramina on the right, though without disruption to the nerve roots.

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T2 Gradient Echo (GE) Neural sleeve cyst; C3-4

Neural sleeve cyst, Right

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T2 FSE; Neural sleeve cyst, C4-5, bilaterally

Neural sleeve cysts visible bilaterally

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T2 Gradient Echo; Neural sleeve cyst, C4-5, bilaterally

Neural sleeve cyst, bilaterally, indicated by heightened signal in the neural foramina

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T2 FSE; Neural sleeve cyst, C5-6, Left

Neural sleeve cyst indicated by heightened signal in the left neural foramina of C5-6

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T2 Gradient Echo; Neural sleeve cyst, C5-6, Left

Neural sleeve cyst indicated by heightened signal in the left neural foramina of C5-6

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T2 FSE; Neural sleeve cyst, C6-7, bilaterally

Cysts demonstrated bilaterally, with heightened signal indicating the largest cyst detected at 4mm, Right

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T2 Gradient Echo; Neural sleeve cyst, C6-7, bilaterally

Cysts demonstrated bilaterally, with heightened signal indicating the largest cyst detected at 4mm, Right

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Sagittal T2

Disc bulges at C4-5, C5-6, and C6-7, with the largest protrusion at the C6-7 level

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FINDINGSCERVICAL MRI, T2MRI images were without contrast, using T2 sequences of fast spin echo (FSE) and gradient echo. T1 images were not obtained, as FSE has been shown to be diagnostically equivalent to T1 imaging in the evaluation of neural structures [7,8].No evidence of acute factures or dislocations, with vertebral bodies within normal limits in height and configurationSmall hemangioma in vertebral body of C5.No evidence of abnormal signal within the visualized cervical spinal cord.Slight reversal and straightening of the mid/upper cervical spine. Mild facet joint arthropathy at C4-5Disc desiccation and mild anterior osteophytes at C4-5, C5-6, C6-7.At C6-7, there is mild posterior disc bulge and subligamentous disc protrusion with mild effacement of anterior subarachnoid space. Borderline central canal stenosis exacerbated by bilateral facet joint arthropathy at C6-7, with mild protrusion disc herniationC6-7 is also significant for bilateral neural foramina narrowing that is slightly worse on the right. Multiple small nerve sleeve cysts are also noted within the neural foramina: C3-4 on the right, C4-5 bilaterally, C5-6 on the left and C6-7 bilaterally.The largest measures 4mm on the right side at C6-7.

DIFFERENTIAL DIAGNOSISWhat is your Differential Diagnosis?Chemical radiculopathy-    -disc degeneration-    -annular tear- Compression radiculopathy:-    -nerve sleeve cysts-    -disc herniation-

Diagnosis: Internal disc disruption with secondary chemical radiculopathy.Dx Confirmed by: Diagnosis was confirmed by T2 MRI findings which indicate that while compressive changes are contributory, they are not the likely etiology of the patient’s symptoms. The MRI is further consistent with the degenerative changes associated with internal disc disruption and resultant chemical radiculopathy.

DISCUSSIONA number of different processes may affect normal nerve function and produce the radicular symptoms and functional disability of this patient. - Compression can affect distal nerve segments, as in carpal tunnel syndrome, as well as proximally at the root level, as in cervical disc herniation. In the latter the herniated or protruding disc may compress the spinal root to produce symptoms of radiculopathy. Any degree of direct compression against a nerve with associated nerve ischemia will produce symptoms.- In its mildest form, the problem may be intermittent due to positioning; in such cases, the pain is most likely secondary to temporary nerve ischemia due to compression. As the compression becomes more consistent and chronic, however, demyelination can occur. Symptoms are usually persistent at this point, and exacerbated by certain movement or positions. Pain and weakness may then become more prominent. In extreme cases, degeneration may occur and distal nerve segments will no longer function; symptoms would be similar to those of nerve transection. - Physiologically, the patient will remain asymptomatic as long as all nerve impulses are transmitted through a region of compression. However, as ischemia or demyelination occurs, nerve conduction will slow down, then eventually may be blocked completely. Diminishing speed of nerve conduction has minimal symptoms, and only the complete conduction block of neuronal impulses will produce substantial functional sensory loss or weakness. This will only occur as the compression worsens [1]. - This patient experiences radiating pain and upper extremity weakness that can be attributed to cervical radiculopathy, primarily on the right side. There is significant compression at the C4-C7 levels due to both disc herniation as well numeral neural sleeve cysts. As mentioned above, any direct compression may produce a nerve ischemia that can produce the situational and positional pain she experiences. However, as also previously discussed, the imaging fails to show complete compression of the nerve roots that would be required to produce the level of pain this patient is experiencing. Neural sleeve cysts, which are commonly asymptomatic, have been noted to produce symptoms only when they exceed 1cm; the largest noted in this case was 4mm [2]. While compression is notable, the neural foramina remains patent bilaterally at these levels both at the sites of disc herniation and cysts. Such imaging findings tend to present with milder symptoms or can even be asymptomatic. This is not the case with our patient. Her function is severely compromised, marked by headaches, weakness, and limitation of recreational activities. Her score of 34 on the Neck Disability Index places her at an assessment of severe disability, verging on complete disability [3]. This is level of pain and compromise of function is inconsistent with the degree of direct compression seen on MRI. - Other possible etiologies of her pain must, therefore, be investigated. In addition to compression radiculopathy, inflammation, or chemical radiculopathy as it is commonly known, can also cause similar symptoms of equal severity. Chemical radiculopathy occurs with the release of inflammatory cytokines and glycoproteins by disrupted annulus fibrosus. The leakage of prostaglandins, phospholipase A2, leukotrienes, and TNF-alpha from the nucleus pulposus irritate the nerve root sheath through a variety of mechanisms [4,5]. They have been found to both directly stimulate nociceptors, producing neuropathic pain, as well as diminish nerve conduction velocities thereby limiting sensory function [6]. - - The patient in this case clearly suffers from a myriad of symptoms indicative of classic cervical radiculopathy, primarily affecting her right side. It is characterized by a radiating neck pain, generalized weakness, and severe disability. Her history of trauma, especially that of her inciting event, is similarly a highly associated risk factor for developing such symptoms. MRI findings also present a multiplicity of possible etiologies for her radiculopathy. There are numerous sources of compression noted in the cervical region, such as disc hernations, bulges, and protrusions, some of which impinge upon the neural foramina. Also of note are several neural sleeve cysts, the largest of which is in a location consistent with her clinical presentation. However, neither the disc bulges nor the cysts seem large enough to produce the symptoms with which she presents, or the severity of the pain she experiences. Interestingly, the MRI also notes dessication and degeneration of the disc in the same location. Such degeneration is often seen in people of her age group, and is also consistent with trauma as well as a history of injury and overuse, which also present in this patient. This dessication is also a primary predisposing factor to developing internal disc disruption which can cause annular tears and the resultant in chemical radiculopathy. - - The diagnosis of radiculopathy is confirmed by the patient*s clinical picture of pain and decreased strength consistent with the condition. Internal disc disruption and the resultant chemical irritation is the likely etiology of her radiculopathy evidenced by the lack of physical compression seen in the cervical MRI. The diagnosis is essentially one of exclusion based on persistent symptoms without mechanical compression seen on imaging. It is further bolstered by the patient*s specific symptomatology and history of injury.- - References:- 1. Carett S, Phil M, Fehling MG. Cervical radiculopathy. NEJM 2005; 353: 392-9.- - 2. Acosta FL, Quinones-Hinojosa A, Schmidt MH. Diagnosis and management of sacral tarlov cysts. Neurosurgery Focus 2003: 15(2).- - 3. Vernon H, Mior S. The neck disability index: a study of reliability and validity. Journal of Manipulative and Physiological Therapeutics 14(7); September 1991.- - 4. Marshall LL, et al. *Chemical radiculitis: A clinical, physiological and immunological- study.* Clin Orthop - 1977:129:61-7- - 5. Malanga GA, Young CC et al. Lumbosacral Radiculopathy. Medscape Reference. -- WEB - Updated February 1, 2012. Accessed February 13, 2012.- - 6. Peng B, Wu W, Li Z, Guo J, Wang X. Chemical radiculitis. Pain, 2007;127(1):11-16- - 7. Lin E. Body MRI Sequences: A conceptual framework. Applied Radiology 41(1): 16-23; 2012.- - 8. Sartorettie-Schefer S, Kollias S, Wichmann W, Valavanis A. T2 Weighted Three-dimensial Fast Spin-Echo in Inflammatory Peripheral Facial Nerve Palsy. Am J Neuroradiology 19:491-495, March 1998.-