Presentation
Tingling and numbness in both hands and right leg. Lhermitte's phenomenon with neck extension. 4/5 weakness in finger abduction and reduced pinprick sensation in medial forearm (right more than left). Upgoing right plantar response.
Patient Data
Severe spinal canal stenosis noted from C4 to C7 particularly at C5/6 and C6/7 due to degenerative disc bulges and congenitally narrow spinal canal which resulting in complete effacement of the CSF and spinal cord compression at these levels. There is high T2 signal noted within the cord due to either edema or myelomalacia. Disc bulge also noted at C4/5 without any myelopathic signal change. Marked bilateral C6/7 foraminal narrowing, worst on the left. Mild foraminal narrowing through remainder of cervical spine.
Summary
- C5/6, C6/7 compressive cervical myelopathy
- Moderate C6/7 foraminal stenosis
Case Discussion
This patient had predominantly sensory symptoms with mild motor deficits and was referred to neurosurgical services for their opinion on decompression.
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