Myelopathy in an Orthopedic Patient: Case Presentation | OEP376

-Today we’ll be discussing a recent patient of mine who presented with left LE paresthesia and difficulty walking.

-I’ll review the evaluation and discuss the management process.

(Video) Hyperthyroidism with myelopathy

(Video) Cervical Myelopathy

(Video) Transverse Myelitis

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Chapters

• 0:00 Introduction and Sponsor Messages
• 1:56 Patient Case Presentation Begins
• 3:47 Clinical Assessment Findings
• 6:51 Neurological Testing Results
• 9:43 Diagnosis and Management Decision
• 11:01 Key Takeaways and Resources

Transcript

Speaker 1: 0:00

Hello everyone and welcome to episode 376 of the OrthoEvalPal podcast. I am your host, paul Marquis PT, and today we're going to be talking about myelopathy in an orthopedic patient. This is going to be a case presentation. Today we'll be discussing a recent patient of mine who presented with left lower extremity paresthesia and difficulty walking walking. I'll review the evaluation process and discuss the management process. I'll throw out this patient's presentation just to kind of show you how you know we sometimes see scenarios in the clinic that may just not follow a straightforward pattern and talk about what to do with those folks. But before we get started, I'd just like to mention our sponsors. We have Rangemaster. Rangemaster is known for their shoulder rehab equipment. They offer products from shoulder wands to finger ladders, overhead pulleys to shoulder rehab kits. Range master is your one-stop shop to help with the treatment of frozen shoulders, post-op rotator cuff repairs, total shoulder and reverse total shoulder replacements and so much more. If you'd like to get a free sample of range master's Blue Ranger pulley system, just email jim at myrangemastercom and add OrthoEvalPal in the subject line. Now we also have MedCorp Professionals. Now I know the folks at MedCorp Professionals personally. They're a locally owned and family operated medical supply company. They carry everything from radial pressure wave units to traction devices, resistance bands to compression garments. Most impressively, though, is their customer service. It's second to none. If you're looking for medical products for your clinic or products for your patients, go to wwwmedcorprocom, and if you use coupon code OEP10, you can get $10 off a Saunders cervical traction unit. Ep10, you can get $10 off a Saunders cervical traction unit, and if you use code FIRSTTIME10, you can get $10 off your first order at Medcor on other products. Welcome back. So I hear a lot of folks who listen to the show say that they enjoy case presentations. I thought that you might find this recent patient encounter interesting.

Speaker 1: 2:02

So here we go. I have this gentleman who comes into the clinic and he's between 45 and 50 years old I don't have his chart in front of me because I'm doing this at home and he comes in with the complaints of significant left lower extremity paresthesia with progressive leg weakness. He has a history of on and off ridiculous symptoms. The last bad episode of sciatica that he had resolved really well in physical therapy I believe that was a couple years ago and he reports that about seven to 10 days ago started to develop this severe left lower extremity paresthesia and what he felt like was progressive, you know lower extremity weakness. So he started using a walker and comes in with that walker today and is very dependent on it, like he's utilizing his arms quite a bit, and he states that this happened really quickly. So this isn't something that was like real progressive but kind of hit him hard. When asked about his upper extremities, he says that they're really not bothering him. All right.

Speaker 1: 3:08

I asked him then about his paresthesia pattern and he says it's pretty much the whole leg. And I asked him about, you know, saddle paresthesia and he said that was significantly worse in the last couple of days but doesn't complain of any significant bowel or bladder incontinence issues or retention problems or anything like that. No real changes there. So he had an MRI of his lumbar spine which showed a herniated disc at one level and I can't remember if it was L4, l5, but there was some sign of bilateral foraminal stenosis which is actually worse on the left side than the left and worse on the right side than the left. Now he stated also that his paresthesias kind of move from side to side periodically. He doesn't report being sick lately or having gone out of the country or somewhere where he could have, you know, gotten something or received something that would have caused, you know, gotten something or received something that would have caused, you know, a virus or a fever or anything like that.

Speaker 1: 4:10

So I started with my evaluation to find that I always start with reflexes pretty much, and so I did his L4 and S1 reflexes bilaterally and they were all hyper reflexive. So whenever I see that, I think to myself well, there are certain diagnoses you know, lower than the thoracic spine that can cause hyper reflexia. So maybe we should go to the upper extremities and as I do that, I do c5, c6 and c7. They are hyper reflexive bilaterally also. So now we have a different picture. We have to be thinking upstream a little bit more at some sort of an upper motor neuron lesion type issue. Now there are some people who are naturally hyper reflexive all the way around and I've seen this.

Speaker 1: 4:58

But we need to be thinking is there something else that could be going on here to be hyper reflexive, both upper and lower? So we need to be thinking is there some sort of a cervical spine cord lesion? Does he have a thyroid condition? Does he have ALS, ms, some sort of neurodegenerative disorder. Is this viral? Does he have a transverse myelitis type of issue? Does he have some sort of a brain lesion? So I asked him did you ever have a significant traumatic brain injury at one point in the past? And the answer was no.

Speaker 1: 5:33

So the next thing I do is some sensory testing, and this is really all over the place. He has significant loss of sensation, more so on the left side than the right. Upper extremities were not significant in regards to altered sensation one side over the other at this time. So then I jump into some manual muscle testing and to my surprise, I only find a couple areas of weakness, and one of them was in his left triceps. So I'm now thinking does he have some sort of a cervical myeloradiculopathy at C7 maybe? And then I also test his extensor hallucis longus to find that that is weak on the left side also. Now, interestingly enough, you'd think that he would have some quadricep weakness, hip flexor weakness, calf weakness, something like that, because of what he feels is his legs giving out, or his leg weakness which requires him to use a walker.

Speaker 2: 6:33

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Speaker 1: 7:12

He states he doesn't think it's really weakness but that he has no idea where his legs are. So he has loss of positional awareness of his legs. So now we need to be thinking more. You know, neurological obviously. So I do a Hoffman's test and he is positive on the left side, not on the right side. He does have some mild clonus on one ankle and I can't really remember which side it was on, to be honest with you, but nonetheless there was some mild clonus that was there. So again we're thinking upper motor neuron lesion here.

Speaker 1: 7:48

I did a Babinski test on both sides but I wasn't able to get a real good test. He actually found this to be quite ticklish and was kind of pulling back, but didn't have the typical upgoing of the toes which happens kind of after the stroke when you have somebody with an upper motor neuron lesion. So I'm throwing that one out the window. His toes were not going down, going either. So then I placed him on the table and I tried. I tested his tricep strength or I had another therapist test his tricep strength to find that it was, you know, weak. It was about four over five and I tractioned him to find no improvement with his tricep strength. So had he had some, you know, nerve root compression or maybe some significant foraminal encroachment at c7? You usually see an improvement in the tricep strength when you traction the neck and retest the strength. So didn't see anything there. So at this stage of the game I'm very concerned. His weakness, I mean his balance, is progressively getting worse, significant amount of paresthesias which kind of move around and he has some signs of upper motor neuron lesion with a positive Hoffman's and hyperreflexia and altered sensation and saddle paresthesia. So I am holding off on physical therapy on this guy. I call his provider who was very suspicious of this also and as a result she had ordered an MRI of his thoracic spine and neck and come to find out he did have some lesions in his neck and even in his brainstem, indicative of MS. So they ordered an MRI of his brain stat and come to find out had some lesions there also. Find out, had some lesions there also. So I guess at this point the findings are driving in the direction of MS. But there are other scenarios that can look like this, some viral issues and whatnot. So apparently he was admitted and given a high dose of steroids. I haven't seen him since.

Speaker 1: 9:56

Now, I am not a neurologist, I'm a physical therapist. I don't even have my DPT or master's degree. I graduated way before all those things existed and so what I'm trying to say here is that the reason I brought this patient situation up is to let you know that you don't need to treat every single patient who comes into your clinic. Okay, um, I communicate with the patient's provider. We both agree that there was something more than just a sciatica type of situation here and that sometimes just recognizing something uh is is all you need to do, and and and giving this patient a different direction, sending them to a specialist, a neurologist, physiatrist, somebody who understands us better and can manage it better, can prescribe the right medication, maybe order other diagnostic tests to help localize this lesion a little bit more and manage it more efficiently. Okay, so we could have, you know, worked on balance. We could have worked on some strengthening. So we could have, you know, worked on balance. We could have worked on some strengthening activities. We could have worked on flexibility and a bunch of other stuff, but I think really expediting this patient to other services was the way to go in this situation, and unfortunately, I do see a lot of patients in this situation, for somebody who primarily sees orthopedic and sports patients, and so I think it's important to recognize when something doesn't look right, to kind of manage it and not just try to treat it.

Speaker 1: 11:23

So I will add some links in the show notes today, including some patients who have myelopathic symptoms, everything from somebody who has a hyperthyroidism to people who have some spinal cord issues. They're quite. Some of these may be quite old, okay, so don't be surprised. I didn't have high def cameras way back when I started on YouTube, but you can still get a good idea of what these look like and what they present like. So I hope you enjoyed today's show and that you all have a great day. If you have questions for me, feel free to send them Questions that you'd like me to put on the show. I'm more than happy to do that, all right. So be kind to each other and take care.