Short Case Presentation Dr Shonali Valsangkar Assistant Professor Neurosurgery Department

Positive History 42 Yrs old right handed male, Clark by occupation Sudden onset neck pain radiating to the lateral aspect of left arm following lifting weight( One and half month back) Tingling numbness followed by weakness in the left UL one and half month back Stiffness in left LL causing loss of balance while walking since 1 month Numbness and paresthesia in right LL (ascending type) since 20 days Altered hot cold sensation on the right LL since 20 days Tingling and numbness in right UL since 20 days Constipation since 20 days Difficulty in passing urine since 20 days

Extent of Lesion Vertical Radiculopathy in the C4 C5,C5 C6 division with sensory loss in the same Cranial nerves – normal Neck muscle power – normal SCM – normal No Horners syndrome Weakness in left UL

Horizontal extent

Positive Signs Muscle bulk normal – no wasting/fasciculations Tone – UL normal , LL hypertonia Power- right left Deltoid 5/5 4/5 Biceps 5/5 4/5 Triceps 5/5 4/5 Wrist f/e 5/5 5/5 P/G Strong Strong LL 5/5 5/5 SCM Rhomboids and trapezius were strong bilaterally

Reflexes DTR- right left Biceps/brachio 3+ 3+ Triceps 3+ 3+ Wartenberg’s + + Hoffman sign + + LL 3+ 3+ Plantars Extensor Extensor Pectoralis 3+ 3+ Deltoid reflex 3 + 3+ Superficial reflexes - absent

Sensations – Pain – decreased in C4 C5 dermatome on the left side Paresthesias on the right side below C6 Touch – Decreased in C4 C5 dermatome on the left side Hot and cold – impaired hot sensation on right side below C6 No sacral sparing

JPS – normal vibration – normal

Summary and Diagnosis Diagnosis- C4 C5 Disc Prolapse 1 . Sudden onset left C4 C5 radiculopathy 2. Spastic parapresis Unilateral spinothalamic tracts Bowel bladder involvement ( Spastic Neurogenic bladder) Diagnosis- C4 C5 Disc Prolapse

Differential Diagnosis 1. Extradural tumor 2. Intradural extra medullary tumor

How to reach diagnosis History— Sudden onset following insult Extra medullary Intra medullary pain Radicular early Burning poor localizing sensory C/L pain and temperature and I/L proprioception Dissociation /spotty changes Symmetry asymmetric symmetric UMN Early prominent late LMN segmental Prominent and wide spread DTR Early markedly brisk Trophic changes Not marked marked Paresthesia progression descending ascending B/B Autonomic changes Late involvement absent Early involvement Present( Horners syndrome) History— Sudden onset following insult Progression

Extradural Tumor IDEM Pain More severe Less severe symmetry + asymmetrical Local pain and deformity absent

Lateral Xray

MRI

MRI

Final diagnosis Anterolateral Compressive extradural lesion C4C5,C5C6 Radiculomyelopathy – Disc Prolapse and lateral recess stenosis

Thank You

Trapezeus- C234XI Rhomboid C45 Serratus anterior C567 Pectorali C5 to T1- brisk lesion C2C3 or C3 C4 XI – C1 to C5 innervates – SCM and upper portion of trapezius