1. Short Case Presentation
Dr Shonali Valsangkar
Assistant Professor
Neurosurgery Department

2. 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

3. 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

4. Horizontal extent

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

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

7. 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

8. JPS – normal
vibration – normal

9. 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

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

11. 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

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

13. Lateral Xray

14. MRI

15. MRI

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

17. Thank You

19. 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