Dr. Michael P. Sluss almost had my diagnosis back in 1990. He did not have a Thoracic spine MRI done on me. Therefore, he missed it. Not sure anyone would have recognized the "Scalpel sign" back in 1990?
"He does have mild tenderness of the upper thoracic spine at about T4." Does this soundlike adead give away! He had it and let it go.
I saw Terry xxxx on December 20. 1990. He is a 36-year-old gentleman who provides the history that almost exactly six years ago, he was hospitalized in Tucson with posterior neck aching and work-up at the time found a protein of approximately 173. Unfortunately. Terry left copies of his medical evaluations at home today. At first, it was suspected that he had mastoid infections but this was determined not to be the case, and essentially no cause was found for his elevated protein or his neck discomfort, which resolved within one week. He states he had a post-spinal headache that lasted about one week, and for that reason, he really has not pursued neurologic re-evaluation since then. One year later, he had the recurrence of his neck pain, and this apparently was triggered when he hyperextended his neck. Since that time, he has had recurrent similar discomfort that seems to be
• aggravated at times with hyperextension of his neck, moving his head quickly. golfing, running or jogging. In fact, during the past year. he tends to have tingling fingertips after jogging. His legs also feel nonspecifically vaguely weak. He has no trouble with urinary or bowel control except has noticed somewhat
• excessive “urine leakage” over the past two to three years. He denies specific neck or head injuries except for occasional bad spills where he may hurt his neck while vigorously doing downhill skiing. He tells me he resided in Tucson from 1976 until September of this year. and denies knowing whether he contracted any clinical coccidiomycoses, although he states that actually before 1981 he was skin tested positive for coccidiomycosis. He does not smoke, he drinks two cans of beer per day, and has no known allergies. He denies doing any exotic traveling. He is married, and works as a mechanical engineer.
I I On examination, mental status is normal. Funduscopic examination is normal. He has full range of motion of the neck. He has no significant cervical spine tenderness nor paraspinal muscle spasm. He does have mild tenderness of the upper thoracic spine at about T4. The deep tendon reflexes are symmetrically intact, except for questionably slightly hyperactive left knee jerk, and Babinski’s are absent bilaterally. Muscle strength and tone are normal. Coordination and gait are normal. Sensory examination is normal.
IMPRESSION:
1. History of elevated CSF protein, with no known etiology.
2. Recurrent episodes of neck pain, bilateral hand tingling, and vaguely weak legs. This certainly sounds suggestive of possible cervical spine disease (cord compression intermittently) but interestingly, neurologic
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
XRAY
DOCTOR M.Sluss ROOM NO. OP DATE 12-20-90
EXAM dorsal sp. cerv sp c flex and exten nd obls.
HISTORY scapular
pain
REPORT:
The cervical spine appears well aligned and the disc spaces are normal. No abnormal motion is seen with flexion and extension. There is no evidence of fracture. No evidence of significant bony stenosis is seen.
IMPRESSION: Normal views of the cervical spine.
Thoracic sp: The thoracic spine appears to be well aligned without evidence of fracture or dislocation. Negative views of the thoracic
W. L. HINGTGSN,M.D.
Radiologist
---------------------------------------------------------------------------------------------------------
MRI CERVICAL
EXAWPATE 12122/gb MRI SCAN 0 9001
REFERRING
MICHAEL P. SLUSS, M.D. (Scans viewed interiorly—
EXAMINATION CERVICAL SPINE superiorly a left—right)
TECHNIQUE 4 or. SAGITTAL TR:SO5 & TE:20
4 umi. En SAGITTAL. TR:flo & TE:23 (20 degrees)
3 or. FEE AXIAL TR:702 a TE:1g (20 degrees)
PREVIOUS
STUDIES Cervical spine films from Bellin Hospital,
HISTORY Numbness and tingling In both hand. and intermittent neck and shoulder pain.
FINDINGS Multiple sagittal and axial views of the cervical spine are obtained The sagittal views are of good Quality and within normal limits. The disc signal is bright throughout the cervical and upper thoracic spine. The cranial cervical Junction is unremarkable. Cord signal is uniform and within normal limits, Axial views from C4—6 through C7—11, Inclusive, are completely within normal limits without evidence of any disc bulging, significant bony changes or intrinsic abnormalities of the cord parsnch~
CONCL,USION Normal I4RI extension of cervical spine,
DEAD BY Stephen V. SomervIlle, M.D.
DICTATED 8V8:mrm
I
12/22/90
I saw Terry in return on December 27. 1990. in follow-up of his back discomfort relieved by aspirin, and previous history of increased protein in his spinal fluid. He again forgot his previous medical records, and he will be mailing me copies of those in the near future. His MRI scan of the cervical spine as well as plane films of his cervical spine and thoracic spine are normal, and this is reassuring. I am checking a serum angiotensin converting enzyme. sed. rate, ANA. rheumatoid factor, FTA absorption, and have asked that he return to see me in one month. I also discussed briefly possibly a nuclear bone scan, but before I order c. -~ any further studies, I do want to see the results of his previous evaluation.
Tips for teasing out a diagnosis of thoracic radiculopathy
When evaluating for thoracic radiculopathy, first evaluate for myelopathy. If this is negative, proceed to evaluate the patient for radiculopathy. Remember, thoracic radiculopathy is an uncommon disorder.
Ask your patient about myelopathic symptoms, including their duration and progression. Thoracic myelopathy will present very similarly to cervical myelopathy, but without upper extremity involvement.
When a patient presents with leg weakness, always consider thoracic myelopathy. Although some lumbar pathologies can cause leg weakness, it is uncommon with lumbar degenerative diseases.
Next, focus on the myelopathy exam. Are the legs truly weak? Is there a sensory level? Any rigidity? Hyperreflexia? Loss of proprioception? Romberg sign? Clonus? Spasticity? With any of these findings, be suspicious of a spinal cord disease above the lumbar spine.
Check for 12 upper motor neuron signs, which would be present in thoracic myelopathy but not in thoracic radiculopathy:
Hyperreflexia
Clonus-causes involuntary muscle contractions or spasms. It leads to muscle tightness and pain.
Babinski sign
Crossed adductor sign
Increased muscle tone
Spasticity
Loss of proprioception
Dermatomal sensory level
Romberg sign
Loss of balance
Spastic gait
Unsteady gait