1. MedPix Medical Image Database COW - Case of the Week Case Contributor: Chan Li-A-Ping Affiliation: SUNY at Buffalo

2. MedPix No: 14481 - History Pt Demographics: Age = 29 y.o. Gender = man 29 y.o. man with no significant past medical history, who presents with complaints of pain in the neck with radiation to the right shoulder. He was involved in a motor vehicle accident on 09/16/YYYY; he was a front seat passenger in a vehicle that was rear-ended by a bus. As per the patient, the vehicle was stopped at a yield sign on an on-ramp to a highway when it was struck from behind. The impact resulted in him striking his right shoulder against the window/door, resulting in immediate neck and back pain. He denies having lost consciousness. He states that he was taken to a local hospital by ambulance; x-rays of his neck and back were obtained. He was prescribed Flexaril and ibuprofen and was subsequently released. Unfortunately, his pain was persistent despite medical therapy, leading him to seek chiropractic therapy. He has been followed in office since 09/24/YYYY.The patients symptoms have been particularly limiting; he reports inability to lift groceries over 20 pounds, significant restriction in overhead movements, and inability to sleep on his right side. Pain is currently rated 7/10 for the right shoulder, and 6/10 for the neck.PAST MEDICAL HISTORY: Past medical history and surgical history is negative. He denies any allergies and does not take any prescribed medications at this time.SYMPTOMS: The patient has described neck pain radiating into the right shoulder, right shoulder pain, and right upper extremity weakness. Downloaded by (-1)

3. MedPix No: 14481 - EXAM & LABS 5 foot 7 inches tall and weighs 198 pounds. Blood pressure of the left arm in the seated position is 104/68 mmHg. Ranges of motion were measured by Dual Inclinometry. Findings were compared to normal from The AMA Guides to the Evaluation of Permanent Impairment 5th Edition. Active range of motion of the cervical spine revealed flexion to be accomplished to 12/50, left rotation to 10/80, right rotation to 20/80, left lateral bending to 22/45, right lateral bending could be performed to 2/45 and extension to 8/60. He reported neck pain during flexion, left rotation, right rotation, right lateral bending and extension. The bicep and tricep reflexes were graded 2/4 bilaterally. Cervical distraction produced reported neck pain. Cervical compression testing produced reported neck pain extending into the right shoulder and right shoulder blade. Active range of motion of the shoulders revealed the right shoulder could only be elevated to 90 with report of right shoulder pain. Neers testing when performed on either side revealed the right shoulder to be elevated to 80 with report of right shoulder pain. The Hawkins-Kennedy and supraspinatus procedures were positive for the right shoulder. Neers testing when performed on the left side revealed the left shoulder to be elevated to 180. The Hawkins-Kennedy and supraspinatus procedures were negative for the left shoulder. Muscle strengths of the upper extremities revealed a weakness of the right bicep, right tricep, right wrist extensors, right finger extensors, and external rotators of the right shoulder. Grip strength was tested using a Jamar dynamometer. The right hand tested to 35 pounds and the left hand tested to 70 pounds. He reports being right hand dominant. Muscle spasm was noted in the right upper trapezius and right posterior neck region. Deep palpation produced reported pain over the anteromedial right shoulder. Deep palpation produced reported pain over the right upper trapezius and medial to the right scapula. EMG evaluation did not reveal radiculopathy. INDICES: The patient completed a Pain Disability Questionnaire and scored 62/150 with 36/90 in the functional category and 26/60 in the psychosocial category. The patient completed a Neck Disability Index Questionnaire and scored 22%. ALGOMETRY: Hyperalgesia was noted in the left upper trapezius, left and right supraspinatus, right infraspinatus, right deltoid, left teres major, & left and right lumbar paraspinals to algometry testing.

4. Plane film AP imaging of the shoulder Other than down sloping acromion essentially normal findings. Downloaded by (-1)

5. Plane film AP imaging of the shoulder Other than down sloping acromion essentially normal findings. Downloaded by (-1)

6. Plane film AP imaging of the shoulder Other than down sloping acromion essentially normal findings. Downloaded by (-1)

7. Axial and coronal imaging of the shoulder. MRI imaging of the shoulder demonstrates bone contusion, SLAP tear and supraspinatus tendinopathy. Downloaded by (-1)

8. MRI imaging of the shoulder in the axial and coronal planes. MRI imaging of the shoulder demonstrates bone contusion, SLAP tear and supraspinatus tendinopathy. Downloaded by (-1)

9. MRI of the Cervical spine C3/C4 level At C3-4 level there is mild posterior disc bulge and focal central asymmetric disc bulging/protrusion with effacement of anterior subarachnoid space flattening the ventral aspect of the thecal sac. There is mild bilateral facet joint arthropathy and uncovertebral joint hypertrophy with no significant neural foraminal narrowing. Downloaded by (-1)

10. MRI imaging at the level of C5/C6 At C5-6 level there is posterior disc bulge and right posterolateral asymmetric disc bulging/protrusion and posterior spurring. Bilateral facet joint arthropathy and uncovertebral joint hypertrophy resulting in mild neural foraminal narrowing on the right. No central canal stenosis noted. Downloaded by (-1)

11. Sagittal and axial imaging at the level of C6/C7. At C6-7 level there is mild posterior disc bulge and posterior spurring slightly asymmetric to the right and mild bilateral facet joint arthropathy with no evidence of central canal stenosis or neural foraminal narrowing. Downloaded by (-1)

12. MRI in the sagittal and axial views of C4/C5 At C4-5 level there is mild posterior disc bulge slightly asymmetric to the right with no evidence of central canal stenosis. There is mild bilateral facet joint arthropathy. No evidence of neural foraminal stenosis. Downloaded by (-1)

13. FINDINGS Cervical MRI: 1.PROMINENT STRAIGHTENING OF CERVICAL SPINE WHICH MIGHT BE SECONDARY TO MUSCLE SPASM. 2.AT C3-4 : MILD POSTERIOR DISC BULGE AND FOCAL CENTRAL ASYMMETRIC DISC BULGING/PROTRUSION WITH EFFACEMENT OF ANTERIOR SUBARACHNOID SPACE FLATTENING THE VENTRAL ASPECT OF THE THECAL SAC. MILD BILATERAL FACET JOINT ARTHROPATHY AND UNCOVERTEBRAL JOINT HYPERTROPHY WITH NO SIGNIFICANT NEURAL FORAMINAL NARROWING. 3.AT C4-5 : MILD POSTERIOR DISC BULGE SLIGHTLY ASYMMETRIC TO THE RIGHT WITH NO EVIDENCE OF CENTRAL CANAL STENOSIS. MILD BILATERAL FACET JOINT ARTHROPATHY. NO EVIDENCE OF NEURAL FORAMINAL STENOSIS. 4.AT C5-6 : POSTERIOR DISC BULGE AND RIGHT POSTEROLATERAL ASYMMETRIC DISC BULGING/PROTRUSION AND POSTERIOR SPURRING. BILATERAL FACET JOINT ARTHROPATHY AND UNCOVERTEBRAL JOINT HYPERTROPHY RESULTING IN MILD NEURAL FORAMINAL NARROWING ON THE RIGHT. 5.AT C6-7 : MILD POSTERIOR DISC BULGE AND POSTERIOR SPURRING SLIGHTLY ASYMMETRIC TO THE RIGHT AND MILD BILATERAL FACET JOINT ARTHROPATHY WITH NO EVIDENCE OF CENTRAL CANAL STENOSIS OR NEURAL FORAMINAL NARROWING.6.MINIMAL RETROLISTHESIS OF C5 OVER C6 SUSPECTED ON LIMITED SCANOGRAM VIEWS. NO DEFINITE EVIDENCE OF SPONDYLOLISTHESIS NOTED ON FLEXION AND EXTENSION VIEWS. HOWEVER, DYNAMIC MOTION X-RAY EVALUATION OF THE CERVICAL SPINE IS A MORE SENSITIVE STUDY TO RULE-OUT SPONDYLOLISTHESIS AND LIGAMENTOUS INSTABILITY/LAXITY. 7.THESE FINDINGS ARE CONSISTENT WITH PHASE II PATHOPHYSIOLOGY OF THE CHIROPRACTIC CLINICAL DIAGNOSIS OF VERTEBRAL SUBLUXATION COMPLEX. CLINICAL CORRELATION IS RECOMMENDED. RIGHT SHOULDER MRI:1.BONE BRUISE/CONTUSION LATERAL HUMERAL HEAD MORE SUPERIORLY. 2.FINDINGS CONSISTENT WITH A LABRAL TEAR, IN PARTICULAR SLAP TEAR. 3.SOME SIGNAL IN THE MID TO DISTAL SUPRASPINATUS TENDON IN FAVOR OF REPRESENTING A TENDINOSIS. 4.SIGNAL ALTERATION SEEN IN THE MID TO DISTAL CLAVICLE. THIS IS NOT SPECIFIC BUT IS NOT SPECIFIC BUT IS NOT FELT TO BE RELATED TO RECENT TRAUMA. DIGITAL MOTION XRAY: -LINK- 1. STRAIGHTENING OF THE NORMAL CERVICAL LORDOSIS IS NOTED.2. C3-4: THERE IS EVIDENCE FOR BOTH ANTERIOR AND POSTERIOR LONGITUDINALLIGAMENT INSTABILITYPLAIN FILM RADIOGRAPHS OF THE SHOULDER:A DOWN SLOPING ACROMION. OTHERWISE NO FRACTURE, DISLOCATION OR OSSEOUS PATHOLOGY.

14. DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Cervical radiculopathy - Peripheral neuropathy - Labral tear - Degenerative disc disease - Cervical spine sprain/strain - Supraspinatus tear/strain - Cervical disc herniation - Lateral Recess stenosis - Intervertebral foraminal stenosis

15. Diagnosis: SLAP Tear and Clinical Cervical Radiculopathy Dx Confirmed by: This diagnosis was confirmed by clinical findings, MRI evaluation and Digital Motion Xray.

16. DISCUSSION In this case the patient has both cervical and shoulder diagnoses. Orthopedic evaluation demonstrated findings suggestive of impingement syndrome and rotator cuff (supraspinatus) lesion. MRI evaluation of the shoulder identified SLAP tear and supraspinatus tendinopathy. MRI evaluation of the cervical spine noted several levels of disc bulging. Electrodiagnostic findings did not demonstrate radiculopathy. In this case the clinical findings do demonstrate findings that would be consistent with radicular motor loss, grip strength diminished on the right and muscle weakness of the biceps, triceps, wrist extensors and external rotators of the right shoulder on the right. The weakness of the right shoulder external rotators can be related to the right shoulder problem. The other motor weakness can be related to cervical origin. As such, it is felt that this patient demonstrates both a shoulder condition, (as noted) as well as a right cervical radiculopathy. Although EMG is specific it is only sensitive in less than 70% of cases (see associated topic).