Patient's Symptoms Worsen Due to Unknown Cause
“Can you please examine my wife carefully and tell me what's wrong with her,” asked Max Small as I entered the exam room. Ruth Small was slumped forward on an examination table, uncharacteristically quiet and appearing to be in acute distress.
Posted in Risk Management on Sunday, November 11, 2018
Mr. Small indicated that Mrs. Small had seen their primary care provider (PCP) twice during the previous week due to progressively worsening complaints. He indicated that the physician was rushed during their visits, and in his opinion, did not perform adequate examinations. The doctor prescribed a different blood pressure medication and reportedly did not address their acute concerns.
I assured Mr. Small I would assess and examine Mrs. Small to the best of my ability. In our office, when returning patients report new health issues, they are asked to provide written, signed and dated updates of their medical history. This includes a description of their chief complaint. Additionally, our patients complete a new pain drawing and rate their pain utilizing a visual analog scale (VAS). With the exception of this new complaint, Mrs. Small denied any recent or interim changes in her medical history. She denied any trauma or illnesses, tests or surgeries.
Pain, Numbness and Weakness Reported
Mrs. Small reported an insidious onset of neck and lower back pain with increasing symptoms over the previous eight days. Her pain was progressively worsening to 8/10 on a VAS with reported disturbances of sleep. She described numbness that affected both legs and was not specific to defined dermatomes. Since seeing her PCP, she experienced abrupt onset of right leg weakness and urinary incontinence that had progressively worsened during the preceding 24 hours. Mrs. Small had difficulty ambulating, requiring the assistance of her husband to walk.
Inspection of Mrs. Small revealed a 66-year-old Caucasian female in acute distress. She weighed 128 pounds and was 64 inches tall. Her blood pressure was slightly elevated at 144/94. She was afebrile. Her pulse was 72 bpm and she took 18 breaths per minute.
The patient was alert and oriented. She exhibited good short- and long-term memory, could identify her husband and was able to perform simple calculations.
Numerous Assessments Performed
Cranial nerve assessment was performed revealing no apparent abnormalities. Otoscopic evaluation was negative. Romberg’s test was positive. Deep tendon reflexes revealed 3/5 responses of the upper extremities and 4/5 patellar and Achilles responses on the right. Bilateral Hoffman responses were elicited. An abdominal reflex was not present. A Babinski response was present on the right. Motor evaluation revealed 3/5 strength of the right lower extremity, which included hip flexion, knee extension, plantar and dorsiflexion of the ankle and inversion/eversion of the foot. Vibratory and joint position sense of the toes of the right foot were impaired.
Chiropractic assessment revealed subluxations at C5/6 and L5/S1 as evidenced by decreased intersegmental motion and hypertonicity affecting the paraspinal musculature in the cervical and lumbar spine regions. The cervical spine ranges of motion were restricted and painful on flexion, extension, lateral flexion and rotation. Notably, the patient exhibited Lhermitte’s sign upon cervical flexion. Lumbar spine ranges of motion were restricted and painful upon flexion and extension. The patient exhibited positive orthopedic tests including: cervical compression, Soto Hall, Kemp’s test, Valsalva maneuver and right straight leg raise in the supine and seated positions.
Cardiovascular examination revealed no apparent abnormalities. Peripheral vascular assessment revealed good perfusion, regular and rhythmic pulses and no edema. Her lungs were clear upon auscultation. Examination of the abdomen revealed no apparent abnormalities. The remainder of the patient’s examination was normal.
Image 1. Image a. T1WI contrast image reveals an ovoid area of enhancement involving the right lateral aspect of the cervical cord from C3-C5, approximately 23 x 5 x 3 millimeters in diameter. Image b. T2 signals change and minimal cord expansion seen from C2 through the C6 levels.
Patient Transported to Hospital
Due to the patient’s rapidly deteriorating condition, I provided a differential diagnosis of acute myelopathy of unknown cause, transient myelitis and Guillain-Barré syndrome. While Mrs. Small was in my office, I called her PCP. I advised him of the patient’s status, my concern for progressive motor deficits and urinary incontinence. He recommended she be immediately transported to the hospital, and he assumed her follow-up care. I carefully documented my examination findings, my discussion with the PCP and her referral to a local hospital.
At the hospital, the physicians performed an MRI of the cervical spine with and without contrast. The attending radiologist noted an ovoid area of enhancement on T1WI contrast imaging involving the right lateral aspect of the cervical cord from C3-C5, approximately 23 x 5 x 3 millimeters in diameter (Image 1a). An abnormality within the cervical cord with hyperintense T2 signal change and minimal cord expansion was visualized from C2 through the C6 level (Image 1b). The abnormality involved the left lateral aspect of the cord substance both anteriorly and posteriorly (Image 2). Extrinsic mass effect upon the cord was not evident.
A neurologic consultation and further testing was performed. Differential considerations included acute transverse myelopathy, demyelinating disease including multiple sclerosis or Lyme myelopathy or infiltrating neoplasms such as lymphoma. A diagnosis of idiopathic transverse myelitis was made and she was treated with intravenous dexamethasone.
I followed up with the patient, having called her to assess her progress over time and notated her clinical progression in her file. Over the following eight weeks, the patient’s symptoms progressively improved. A subsequent MRI of the cervical spine with and without contrast revealed nearly complete resolution of cervical cord abnormalities.
Unfortunately, six months later, the patient suffered a relapse and was diagnosed with recurring idiopathic transverse myelitis. To date, the patient’s neurologist has been unable to provide her with a definitive etiology for her condition.
Image 2. Axial T1WI with contrast reveals the abnormality involved at the left lateral aspect of the cord substance both anteriorly and posteriorly.
Dr. James Demetrious is a distinguished Fellow of the Academy of Chiropractic Orthopedists. He conducts a private practice in Wilmington, North Carolina. He teaches advanced post-graduate chiropractic coursework throughout the U.S. on behalf of the NCMIC Speakers Bureau.