• HPI: 58 year old woman presents with 3 month history of intermittent left-sided neck and constant arm pain. He describes the neck pain as dull in nature with “shooting” radicular pain to the left arm/hand in the C7 distribution. He denies any right arm symptoms. He has taken Tylenol and Motrin but with minimal improvement. He underwent a selective C6/C7 foraminal nerve root block with relief of symptoms for about 1 week. A second injection made his symptoms worse. He denies any leg pain and no bowel or bladder dysfunction. There is no history of trauma. Since that time he has had a dull headache and neck stiffness and no other symptoms. The ER physician does a lumbar puncture and frank blood is seen. A CT Head without contrast is completed and shows hyperdensity consistent with blood products in the posterior fossa. The patient is subsequently transferred to a tertiary care center. 

    PMH: 
    1. Unremarkable 

    Family Hx: 
    Mother died from breast cancer. Father is not alive but was very healthy. 

    Medications: 
    1. Fish Oil 

    Social History: 
    He is married. He has a long history of tobacco abuse (1/2 pack / day). Alcohol use is rare. No illicit drug use history. 

    Neurological Exam: 
    Strength in bilateral upper and lower extremities is 5/5 in grip, biceps, deltoid, hip flexor-extensor, knee flexor-extensor, dorsiflexion and plantar flexion and 4/5 left triceps. Sensation to light touch is intact throughout except left C7 dermatomal distribution. Reflexes are 1 and symmetric throughout. Toes are downgoing toes bilaterally. Hoffman and Rhomberg are negative.

    HPI: 58 year old woman presents with 3 month history of intermittent left-sided neck and constant arm pain. He describes the neck pain as dull in nature with “shooting” radicular pain to the left arm/hand in the C7 distribution. He denies any right arm symptoms. He has taken Tylenol and Motrin but with minimal improvement. He underwent a selective C6/C7 foraminal nerve root block with relief of symptoms for about 1 week. A second injection made his symptoms worse. He denies any leg pain and no bowel or bladder dysfunction. There is no history of trauma. Since that time he has had a dull headache and neck stiffness and no other symptoms. The ER physician does a lumbar puncture and frank blood is seen. A CT Head without contrast is completed and shows hyperdensity consistent with blood products in the posterior fossa. The patient is subsequently transferred to a tertiary care center. 

    PMH: 
    1. Unremarkable 

    Family Hx: 
    Mother died from breast cancer. Father is not alive but was very healthy. 

    Medications: 
    1. Fish Oil 

    Social History: 
    He is married. He has a long history of tobacco abuse (1/2 pack / day). Alcohol use is rare. No illicit drug use history. 

    Neurological Exam: 
    Strength in bilateral upper and lower extremities is 5/5 in grip, biceps, deltoid, hip flexor-extensor, knee flexor-extensor, dorsiflexion and plantar flexion and 4/5 left triceps. Sensation to light touch is intact throughout except left C7 dermatomal distribution. Reflexes are 1 and symmetric throughout. Toes are downgoing toes bilaterally. Hoffman and Rhomberg are negative.

    Figure 1. T2 MRI Midline sagittal

    Figure 2. T2 MRI Left para-midline sagittal

     

    Figure 3. T2 MRI Axial through C6/C7 foramen

    1. Would you proceed with additional conservative measures at this time?

    2. You decide to proceed with surgery, which of the following procedures would you perform?

    3. Please add any suggestions or comments regarding this case:

    • therapy for two weeks, if no change then would go with ACD C6/7 with fusion. I would use bengal cage, BCP and no plate.
    • would also do CTA to delinate cause of p fossa bleed b4 i do the ACDF at C6/7
    • This looks like a pre-exisiting left C6/7 lateral disk with complication of an epidural hematoma related to the "conservative measure". With a focal deficit and now hemorrhage a laminectomy/foraminotomy at that level would be wise.
    • Patient has SAH, so I would postpone any spine intervention untill appropriate work up is done to r/o possible VA dissection/posterior circulation aneurysm/avm. Would start with CT angio.
    • I will do CT of the relevant level before proceeding with surgery
    • this patient has motor deficit which is a strong indication for surgery. he has unilateral radiculopathy without any signs or symptoms of myelopathy. the disc being paracentral and the fact that he has had relief with root block once, favours unilateral posterior foraminotomy +/- discectomy.
    • replacement of disc by cage medtronic
    • I was unable to enlarge the films by clicking on them.

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