Cervical Disk Hernia_1
Short Summary

62-year-old male complained about sensation of pins and needles in the fingers accompanied by pain and feeling of pressure in the toes. The patient underwent CT and MRT of the cervical spine and conduction studies that showed signs of severe chronic neuropathy, Lordosis, disc hernias with pressure on the dural sac and narrowing of the canal together with segment myelopathy and spinal stenosis. In light of the weakness of the muscles in the patient's right hand, the expert recommendes a surgical solution.

Patient's Questions
Medical Background

Age: 62. Diagnosis: Cervical Disk Hernia
Past medical history:

  • Hypertension
  • Shortness of breath of unknown aetiology
  • Three years ago a melanoma was removed from the left side of the chest wall.
Presenting Complaint: One year history of pins and needles in all the fingers of the right hand which has gradually worsened and which has since been accompanied by pain.
On the left hand there is a similar feeling but to a lesser extent.
Over the past two months there has been an intermittent feeling of pressure in the toes.
There is no gait disturbance.
The investigations performed up to now.
EMG upper limbs – Neuropathy mainly on Right C5-6
CT cervical spine – 12. 2007 lordosis until a segmentary kyphosis, large anterior ostephytes, at the connections from C4-7, large disc hernia C3-4 , narrowing the canal severely, slight narrowing at C6-7.
 
MRT cervical spine 01.2008 large disc hernia c3-4, no clear myelopathy (the radiology report noted a point of myelopathy)
 
Physical examination:
Normal gait
Reduction on neck movement
Upper arm strength – weakened R interossei 4/5, the rest of the upper limb muscles have normal strength
No spasticity in the upper limb, weak tendon reflexes (more so on the right).
 
Hoffman and Tromner sign negative on both upper limbs. Normal sensation.
Upper limbs – There is no spasticity, motor or sensory loss, (including propioception). There are normal tendon reflexes and bilateral negative Babinski.
CT of the cervical spine
 
This is a CT of the cervical spine due to neck pain that radiates to the arms.
There is no collapse or dislocation.
There is severe degenerative change and a natural lordosis at the anterior aspects of C4,5,6 with a relative reduction of height of C6 and a narrowing of the intervertebral disc of C6-7.
C2-3 there is a posterior disc hernia pressing on the dural sac.
C3-4 there is severe narrowing of the facet joints with bilateral pressure on the roots with a severe posterior disc hernia with severe pressure on the dural sack.
C4-5 there is a narrowing of the intervertebral foramen with a chronic herniated disc pressing on the dural sac and narrows the foramen mainly on the left side.
C5-6 there is narrowing of the intervertebral foramen, narrowing of the spinal canal, a diffuse chronic disc hernia with severe pressure on the dural sack and the roots.
C6-7 there is severe narrowing of the intervertebral disc, severe narrowing of the intervertebral foramen with a diffuse chronic hernia pressuring on the dural sack and the roots.
 
Summary: Severe degenerative changes of the spine.
 
 
 

 
EMG 01/2008  
 
 
Summary:
The conduction studies including F waves at the border of the normal range when one takes into account the height of the patient
No evidence of carpal tunnel syndrome or polyneuropathy
Root    Muscle    Spontaneous activity    Form of the Potentials    Recruitment
          R    L    R    L    R    L
C5-6    Deltoid    none    none    polyphasic         Mildly reduced    Full
C5-6    Biceps    none         polyphasic         Reduced    
C6-8    Triceps    none         Normal         Full    
C7-8    A.P.B.    none         Normal         Full    
 
Summary
Signs of severe chronic neuropathy in the patients muscles whose roots are C5-6 on the right.
 
This examination allows a closer assessment of the extent of neurological damage.
A full assessment of the patient depends on all the clinical information and on other investigations.
The F waves measured here are on the shortest wave. The sensory reaction is measured at the peak of the wave.
 
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MRT cervical spine.
Lordosis of the spine.
Disc hernias at C3-4-, C5-6, C6-7 with the most sever at C3-4 with severe pressure on the dural sac and sever narrowing of the canal at that level. At the same intervertebral segment there is segment myelopathy of the cord. The rest of the chord is normal.
Expert's Opinion
Discussion and conclusions
This is an atypical clinical picture – there is no clear picture of myelopathy.
There is a suspicion of neurological disturbance – a thorough neurological investigation has to be completed.
The findings of the investigations are very impressive (sic ) – severe pressure at the level C3-4. In light of the slight weakness of the muscles in the right hand, one should consider a surgical solution. (in light of the degree of narrowing – it is preferable to combine a posterior approach and after this anterior ) . As there are no severe neurological deficits, one should complete the full neurological investigation and only after this perform a surgical solution. One should refrain from being in all situations that may damage the cervical spine such as minimal trauma, chiropractor etc.
Before the operation one should perform an MRI of a higher quality.

Expert's Opinion

his is an atypical clinical picture – there is no clear picture of myelopathy.
There is a suspicion of neurological disturbance – a thorough neurological investigation has to be completed.
The findings of the investigations are very impressive (sic ) – severe pressure at the level C3-4. In light of the slight weakness of the muscles in the right hand, one should consider a surgical solution. (in light of the degree of narrowing – it is preferable to combine a posterior approach and after this anterior ) . As there are no severe neurological deficits, one should complete the full neurological investigation and only after this perform a surgical solution. One should refrain from being in all situations that may damage the cervical spine such as minimal trauma, chiropractor etc.
Before the operation one should perform an MRI of a higher quality.

 

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