The Case: 49-year-old male with no significant past medical history presented to the ED for progressive neck pain and bilateral upper extremity weakness in a cape-like distribution for 6 months, worsening over the past week. Notably, the patient was in a motorcycle accident in a foreign country 6 months earlier, when he was struck from behind and ejected from his vehicle, landing on his left side. He states that he lost consciousness for 3 minutes at the time of injury, and he received MR imaging of his cervical spine at that time that was unremarkable for acute pathology. He was discharged to home and received no further neurological follow-up following the injury.
Since the time of injury, the patient has had progressive bilateral upper extremity weakness, greater on his left side. Over the past week, the weakness progressed to the point where he was unable to lift his arms over his head above chin-level. He therefore could no longer perform ADLs like washing his face or brushing his teeth without assistance. He also endorsed mild, sharp right neck pain that had been present since the time of the motorcycle accident and worsened over the past week, especially when turning his head to the right. He otherwise denied numbness, tingling, or shooting pain into his arms.
On exam, the patient had no cranial nerve deficits. Palpation of the neck elicited right cervical paraspinal tenderness. His motor exam revealed significant deficits, including muscle strength of 2/5 on bilateral shoulder abduction, 4/5 on elbow flexion and elbow extension, and 5/5 on wrist flexion, wrist extension, grip, finger extension, finger flexion, and finger abduction. There was also bilateral deltoid muscle atrophy with normal tone. Sensation was diminished to light touch over the bilateral C4 and C5 dermatomal distributions. An MRI of the cervical spine was ordered immediately in the ED given the patient’s progressive neurological findings.
The Image:
Three Questions:
1. What is in your differential? How does it relate to the MRI findings?
2. How does the image correlate with the patient’s physical exam findings, especially his motor and sensory deficits?
3. Based on the MRI findings, what is the next step in management and disposition for this patient?
Answers:
1. Discussion: Classically, weakness in a bilateral “cape-like” distribution of the upper extremities is associated with syringomyelia, AKA syrinx. Syringomyelia is a rare but important complication of trauma, particularly cervical spine trauma, and may not appear for months-to-years after the initial spinal cord injury. In many cases, it occurs secondary to compressive forces on the spinal cord that occurred at the time of initial injury.
DDx: Syrinx, cervical cord compression secondary to mass effect, central cord syndrome, bilateral spinal stenosis from disc herniations
MRI Findings: Patient was found to have atrophy of the spinal cord from C2-C6, particularly at the C5-C6 level, representing compressive myelopathy that possibly occurred secondary to a since-resolved post-traumatic epidural hematoma, as well as disc osteophyte complexes at C5-C6 and C6-C7 levels.
2. C5 nerve, which is the primary distribution of sensory deficits and a level at which spinal cord and disc changes were seen, is responsible for shoulder abduction and elbow flexion, which were weakened in our patient. C4 sensory distribution was also reduced in our patient.
3. Neurology was consulted and the patient was admitted for further neurology workup. Neurosurgery was not consulted, as there was not a well visualized syrinx or epidural hematoma to be evacuated. Per a literature review afterwards, Neurosurgery need not be involved in the patient’s care if there is no longer a syrinx or hematoma to intervene on.
Learning Points:
Delayed motor and sensory deficits are relatively rare but significant complications of spinal cord trauma. For patients with unexplained weakness, particularly bilaterally, it is important to elicit a thorough history that may point to any trauma that the patient may have sustained, even months or years in the past. Any concern for spinal cord compression or trauma should prompt immediate MRI in the ED for further evaluation and characterization of the patient’s symptoms (1). Delays in care, as seen in our patient, can lead to poor neurological outcomes (1,2).
In many cases, spinal cord compression secondary to trauma will present with moderate-to-severe neck/back pain, often with radiculopathy, which may progress to motor weakness and/or sensory deficits months-to-years after the initial injury (3). Differential diagnoses include post-traumatic syringomyelia, compressive myelopathy from an expanding spinal epidural/subdural hematoma, central cord syndrome, or herniated disc causing bilateral spinal stenosis with radiculopathy, among others (4). Chronic compressive or mechanical stress on the spinal cord has been well documented to increase the risk of syrinx and secondary spinal cord changes. The likelihood of permanent neurological sequelae, including permanent paraplegia, is increased the longer that definitive diagnosis and management is delayed (5).
On our patient’s MRI, while a syrinx was not observed, a noticeable compressive myelopathy from C2-C6, particularly at C5-C6, was visualized with anterior spinal cord atrophy. Without a definitive syrinx or epidural hematoma on MR imaging, symptoms were attributed to a compressive myelopathy with spinal cord atrophy likely secondary to a post-traumatic epidural hematoma, which has since resolved but was not immediately evacuated, resulting in progressive neurological deficits. The patient was admitted to the hospital for further neurological evaluation by Neurology, and further MR imaging and EMGs were recommended in 1 week, or sooner if neurological symptoms continued to progress.
Written by:
Michael Dorritie, MD
PGY-1
Emergency Department
Cook County Hospital
Reviewed by:
Micheal Schindlbeck, MD
Program Director
Emergency Department
Cook County Hospital
Resources:
1. Braun P, Kazmi K, Nogués-Meléndez P, Mas-Estellés F, Aparici-Robles F. MRI findings in spinal subdural and epidural hematomas. Eur J Radiol. 2007;64(1):119. Epub2007 Mar 13. PMID 17353109.
2. Lawton MT, Porter RW, Heiserman JE, Jacobowitz R, Sonntag VK, Dickman CA. Surgical management of spinal epidural hematoma: relationship between surgical timing and neurological outcome. J Neurosurg. 1995;83(1):1. PMID: 7782824.
3. Thiele RH, Hage ZA, Surdell DL, Ondra SL, Batjer HH, Bendok BR. Spontaneous spinal epudiral hematoma of unknown etiology: case report and literature review. Neurocrit Care. 2008;9(2):242. PMID: 18373224.
4. Brodbelt AR, Stoodley MA. Post-traumatic syringomyelia: a review. J Clin Neurosci. 2003;10(4):401. PMID: 12852875.
5. Abel R, Gerner HJ, Smit C, Meiners T. Residual deformity of the spinal canal in patients with traumatic paraplegia and secondary changes of the spinal cord. Spinal Cord. 1999;37(1):14. PMID: 10025689.