1. MedPix Medical Image Database COW - Case of the Week Case Contributor: Joan Chi Affiliation: SUNY at Buffalo

2. MedPix No: 14487 - History Pt Demographics: Age = 69 y.o. Gender = man 69yo AAM with hx of CAD, HTN, hypercholesterolemia, CABG in 1983, cardiac stents in 2012, and cardiac device placement in 2012 presents with right shoulder pain s/p MVA two months ago. Patient was at a red light when a sedan hit him from behind. He had his seat belt on and his air bags did not deploy. Pt states he was holding the steering wheel with his right hand with a very strong grip and he was pressing on his brakes when the car hit him from behind. He did not hit his head on the steering wheel and he did not lose consciousness. He went to the ER immediately after the accident, where he had plain xrays of his neck and shoulder that showed no fractures at the time. Patient continued to have neck and left upper extremity pain as well as right shoulder pain that woke him up from his sleep. He had a pacemaker placed and was unable to have an MRI. He had CT scan of the cervical spine and one month later following the MVA had a CT arthrogram for his shoulder. Downloaded by (-1)

3. MedPix No: 14487 - EXAM & LABS PE: General appearance: well developed male in NAD Head: normocephalic, atraumatic. Neck: Cervical compression testing produced report of cervical pain with sharp pain radiating to left arm. Shoulder: Tender on palpation of right anteromedial shoulder. No erythema, no edema of right shoulder. Motor: Decreased flexion and extension of neck, decreased lateral flexion of the neck, limited rotation of neck. Decreased abduction of right arm up to 110 degrees. 5/5 motor strength in left arm, 3/5 motor strength in right arm. 5/5 strength in left forearm, 3/5 strength in right forearm. Sensation: Sensation intact in upper extremities bilaterally. DTR: 2+ triceps, biceps reflexes bilaterally.

4. CT Cervical Spine C2-C3 PARTIAL CONGENITAL FUSION OF C2 AND C3. Downloaded by (-1)

5. CT Cervical spine- C3-C4 C3-C4: SMALL LEFT PARACENTRAL DISC HERNIATION Downloaded by (-1)

6. CT Cervical spine- C4-C5 C4-C5: MILD SPONDYLOSIS AND DISC BULGE. Downloaded by (-1)

7. CT Cervical spine- C5-C6 C5-C6: DORSAL DISC OSTEOPHYTE COMPLEX WHICH IS ASYMMETRIC TO THE LEFT. THERE IS FORAMINAL STENOSIS, GREATER ON THE LEFT SIDE. Downloaded by (-1)

8. CT Cervical spine- C6-C7 C6-C7: DORSAL DISC OSTEOPHYTE COMPLEX AND MODEWRATE BILATERAL FORAMINAL STENOSIS Downloaded by (-1)

9. CT Cervical spine- C2-C3 Replace this - DESCRIPTION OF THE IMAGE OR FINDINGS. Downloaded by (-1)

10. CT shoulder There are no dislocations or fractures. The biceps tendon and sheath are within normal limits. There is extravasation of contrast from the joint space into the subacromial/subdeltoid bursae with the presence of a complete rotator cuff tear. There is an area of discontinuity at the supraspinatus tendon adjacent to the greater tuberosity. Downloaded by (-1)

11. CT Cervical spine Ossification of nuchal ligament. Downloaded by (-1)

12. CT Arthrogram Replace this - DESCRIPTION OF THE IMAGE OR FINDINGS. Downloaded by (-1)

13. X ray Shoulder Replace this - DESCRIPTION OF THE IMAGE OR FINDINGS. Downloaded by (-1)

14. Xray Shoulder Replace this - DESCRIPTION OF THE IMAGE OR FINDINGS. Downloaded by (-1)

15. Xray Shoulder Replace this - DESCRIPTION OF THE IMAGE OR FINDINGS. Downloaded by (-1)

16. FINDINGS CT Arthrogram There is no acute fracture or dislocation of the visualized skeletal structures. Mild degenerative changes are noted at the right acromioclavicular joint with minimal inferior spurring. The acromioclavicular joint is, otherwise, maintained. The biceps tendon and tendon sheath appear essentially within normal limits as visualized. The glenohumeral ligaments are unremarkable. There is extravasation of contrast from the joint space into the subacromial/subdeltoid bursae compatible with the presence of a complete tear of the rotator cuff. Area of discontinuity is evident at the supraspinatus tendon adjacent to the greater tuberosity. CT Cervical Spine NO EVIDENCE OF FRACTURE. PARTIAL CONGENITAL FUSION OF C2 AND C3. DEGENERATIVE CHANGES ARE NOTED AT C1-C2 WITH OSTEOPHYTES AND CALCIFICATION OF THE TRANSVERSE LIGAMENT. C3-C4: SMALL LEFT PARACENTRAL DISC HERNIATION. C4-C5: MILD SPONDYLOSIS AND DISC BULGE. C5-C6: DORSAL DISC OSTEOPHYTE COMPLEX WHICH IS ASYMMETRIC TO THE LEFT. THERE IS FORAMINAL STENOSIS, GREATER ON THE LEFT. C6-C7: DORSAL DISC OSTEOPHYTE COMPLEX AND MODERATE BILATERAL FORAMINAL STENOSISEMG:Positive sharp waves in the cervical paraspinal muscles at the level of C5/C6.

17. DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Rotator cuff tear - Rotator cuff tendinopathy - Musculoskeletal strain - Acromioclavicular injury - Bicipital tendonitis - Cervical radiculopathy - Shoulder instability -

18. Diagnosis: Rotator Cuff Tear and left C5 and C6 radiculopathy. Dx Confirmed by: CT Arthrogram. CT scan of the cervical spine demonstrated IVF encroachment at the level of C5/C6 on the left side. EMG demonstrated C5-C6 radiculopathy.

19. DISCUSSION Patient had decreased range of motion and pain in his right shoulder due to his rotator cuff tear. He also experienced radiculopathy in his left arm due to neural compromise. Such cervical region was not bothering him prior to the MVA. However, following the accelerative and decelerative effects of MVA nerve injury was sustained. A poor platform of degenerative disc changes as evident in his CT spine with IVF narrowing was present prior to the MVA and such pre-existing components contributed to the cervical radiculopathy. Cervical compression testing procedures accentuate neurophysiological compression on physical exam with resultant reduplication of symptoms.. Although his CT spine showed chronic degenerative changes, his EMG showed positive sharp waves in his paraspinal muscles which are evident for damage to motor axons that have occurred acutely, within 1week-12 months [1]. Contributor GG/GS suggests that EMG not be performed at least 4 weeks following the episode of injury and ideally up to 6-8 weeks following the episode. - - In this particular patient, his left and right arm pain were from different sources. It is possible that a patient can present with pain from a rotator cuff tear and radiculopathy on the same side, which is challenging for a clinician to know where the source of pain emanates from. Patients with cervical radiculopathy often present with neck and arm discomfort of insidious onset. Typically the pain is in the shoulder with pain radiating to the upper or lower arm where the nerve root is involved. Patients will often present with decreased extension, rotation, and lateral bending of the neck, with pain on palpation of cervical spine muscles, and/or loss of sensation in the appropriate dermatomal distribution. Patient may also have a positive foraminal compression test. - - Patients with rotator cuff injury often describe pain, weakness, and loss of shoulder motion with pain exacerbated by overhead activities. It is also common to have pain at night when sleeping on the affected shoulder. Patients with rotator cuff tears usually have tenderness on palpation of the greater tuberosity and subacromial bursa, a decrease in glenohumeral motion, and decreased abduction due to pain in the range of 60-120 degrees. There are also certain tests that can be performed such as the Neer*s Impingement test, in which the shoulder is forcibly forward flexed and internally rotated causing the greater tuberosity to jam against the anterior inferior surface of the acromion. Pain suggests injury to the supraspinatus tendon. The Hawkins-Kennedy Impingement test is performed by forward flexing the shoulder and elbow to 90 degrees and forcibly internally rotating the shoulder. Pain indicates positive test when there is damage to the supraspinatus tendon. The Apprehension test can also be performed which involves abducting the arm 90degrees, externally rotating, and pushing force onto the posterior humeral head from behind. Such test when positive is indicative of instability. - - 1.Feinberg JH (2006) EMG myths and facts. Hospital for Special Surgery Journal 2:1921