A 45 year old male presents with right-sided neck pain with no recent history of trauma. The patient had been involved in a head-on motor vehicle accident eight years previously during which he was knocked unconscious and after which he immediately experienced neck and right shoulder pain. For three years after the accident the patient saw several specialists for cervical radiculopathy and reported that his symptoms abated following a cervical fusion at C6-7. Since that time, the patient had no episodes of neck or shoulder pain although he reported his neck was stiff in all directions. The patient also reported that the latest episode of neck pain began two weeks ago when he woke up in the morning. The patient’s past medical and surgical history were unremarkable although a recent MRI (taken one month ago) showed disk protrusions at C3-4 and C5-6, but with no evidence of nerve root impingement.
Is there anything in this history that should be of concern?
The patient office he sustained a fairly serious injury, albeit eight years ago, and has also undergone a cervical fusion. The insidious onset of the pain should be of concern, but based on the history alone it would be impossible for the clinician to determine a diagnosis.
Does the patient warrant an upper quarter screening examination?
This patient warrants an upper quarter screening examination.
The physical examination revealed the following positive findings:
- Observation revealed no specific deficits in posture or alignment.
- Palpation of the paravertebral muscles of the cervical spine elicited pain on the right side at both the C1 and C4-7 levels.
- The deep tendon reflexes in the upper extremities were normal but the ankle jerks were somewhat diminished bilaterally (1+). All other neurologic tests were normal.
- Active cervical range of motion was restricted by approximately 50% in all directions.
Following the physical examination, what is your working hypothesis and your course of action?
This last case study is a very difficult one that demonstrates how important it is for clinicians to be able to relate signs and symptoms to the relevant anatomy of the spine. The only ‘significant’ findings were the history of severe trauma and the presence of diminished reflexes at the ankles, the latter of which can sometimes occur normally. The recent MRI highlighted disk protrusions but the physical examination demonstrated no evidence of nerve root Involvement. In this case, the plan should be to address the right-sided neck pain while continuing to monitor for any adverse signs and symptoms.
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