Short Case Presentation Dr Shonali Valsangkar Assistant Professor

Short Case Presentation Dr Shonali Valsangkar Assistant Professor Neurosurgery Department

Positive History • 42 Yrs old right handed male, Clark by occupation • Sudden onset neck pain radiating to the lateral aspect of left arm following lifting weight( One and half month back) • Tingling numbness followed by weakness in the left UL one and half month back • Stiffness in left LL causing loss of balance while walking since 1 month • Numbness and paresthesia in right LL (ascending type) since 20 days • Altered hot cold sensation on the right LL since 20 days • Tingling and numbness in right UL since 20 days • Constipation since 20 days • Difficulty in passing urine since 20 days

Extent of Lesion Vertical Radiculopathy in the C 4 C 5, C 5 C 6 division with sensory loss in the same • Cranial nerves – normal • Neck muscle power – normal • SCM – normal • No Horners syndrome • Weakness in left UL

Horizontal extent

Positive Signs • • • Muscle bulk normal – no wasting/fasciculations Tone – UL normal , LL hypertonia Powerright left Deltoid 5/5 4/5 Biceps 5/5 4/5 Triceps 5/5 4/5 Wrist f/e 5/5 P/G Strong LL 5/5 SCM Rhomboids and trapezius were strong bilaterally

Reflexes • DTRright left • Biceps/brachio 3+ 3+ • Triceps 3+ 3+ • Wartenberg’s + + • Hoffman sign + + • LL 3+ 3+ • Plantars Extensor • Pectoralis 3+ 3+ • Deltoid reflex 3+ 3+ • Superficial reflexes - absent

Sensations – • Pain – decreased in C 4 C 5 dermatome on the left side • Paresthesias on the right side below C 6 • Touch – Decreased in C 4 C 5 dermatome on the left side • Hot and cold – impaired hot sensation on right side below C 6 • No sacral sparing

• JPS – normal • vibration – normal

Summary and Diagnosis 1. Sudden onset left C 4 C 5 radiculopathy 2. Spastic parapresis 3. Unilateral spinothalamic tracts 4. Bowel bladder involvement ( Spastic Neurogenic bladder) Diagnosis- C 4 C 5 Disc Prolapse

Differential Diagnosis • 1. Extradural tumor • 2. Intradural extra medullary tumor

How to reach diagnosis Extra medullary • History— sensory C/L pain and temperature and I/L proprioception • Sudden onset following insult Symmetry asymmetric • Progression pain Radicular early Intra medullary Burning poor localizing Dissociation /spotty changes symmetric UMN Early prominent late LMN segmental Prominent and wide spread DTR Early markedly brisk late Trophic changes Not marked Paresthesia progression descending ascending B/B Autonomic changes Late involvement absent Early involvement Present( Horners syndrome)

Extradural Tumor IDEM Pain More severe Less severe symmetry + asymmetrical Local pain and deformity + absent

Lateral Xray

MRI

MRI

Final diagnosis • Anterolateral Compressive extradural lesion C 4 C 5, C 5 C 6 Radiculomyelopathy – Disc Prolapse and lateral recess stenosis

Thank You

• • • Trapezeus- C 234 XI Rhomboid C 45 Serratus anterior C 567 Pectorali C 5 to T 1 - brisk lesion C 2 C 3 or C 3 C 4 XI – C 1 to C 5 innervates – SCM and upper portion of trapezius