Case of the week: 29-11-2004

Atypical Gait Disorder


Upper-limb Symptoms

Immediate symptoms developed Oct 2002 (10 days post-op)
• Pain mid-cervical to top of left shoulder
• Left shoulder blade pain
• Numbness top of left shoulder
• Tingling left hand, mostly 1st three fingers with decreased sensation
• Occasional color change in left hand - mottled appearance
• Difficulty spreading fingers apart on left with impaired fine motor control, occasionally dropping items
• Weakness left arm
• Unable to raise arm higher than level of shoulder - as if shoulder was paralyzed
• Unable to lift half gallon of milk or heavier object
• Muscle twitching noted mostly left biceps, triceps and left upper thigh area initially - now mostly left side, with occasional twitching in right arm
• Numbness in right hand periodically - sometimes whole hand including 5th finger (occurs if lying on either right or left side), or just right thumb

Leg symptoms

Initial leg symptoms appeared March 2003
• Numbness left toes March 2003
• Slower walking July 2003
• Numbness right toes August 2003
• Limping started September 2003
• Weakness left leg more apparent to patient October 2003
• Bilateral toe sensation like “shoes too tight”
  • Neck pain greatly reduced with in supine position, but hand tingling and shoulder blade pain worse
  • Arm pain present when head thrust to left or head tilted to left and axially compressed
  • Bumpy car rides increase pain and tingling
  • Position of head to right side while lying flat corrects shoulder problem (not possible if up all day). Initially if my head was flat and slightly hyperextended I could raise my arm completely over head and lift heavy object-unable to duplicate this for over a year.
  • Bilateral foot tightness sensation not present first thing in morning after lying supine all night - but commence immediately on rising
  • Summary of imaging and other studies done to date

    November 13, 2002 CBC, ESR: Normal, no infection

    November 14, 2002 Cervical MRI: asymmetrical bulging on left at C5-6 but no compression seen, most likely post-op changes

    December 2, 2002 EMG done by Neurology: C7 Radiculopathy acute and chronic.

    December 18, 2002  CT Myelogram: some C7 anterior sleeve filling defect, probably post-op in nature.

    January 15, 2003  Cervical spine x-rays: no instability

    January 23, 2003 EMG  (results [verbal] identical to EMG performed 12/02/02-active C7 radiculopathy

    February 14, 2003  cranial MRI: normal

    June 20, 2003 Stand up MRI: Bulging at 2-3, 3-4 impinging on thecal sac, posterior central herniation impinging on cord, minimal narrowing, ventral and dorsal marginal osteophytes, diffuse bulging at 5-6, 6-7 impinging on ventral thecal sac and minimal narrowing of 5-6, 6-7 neural foramina bilaterally, straightening and desiccation of all disks.  T4 and 5 vertebral body lesions probably representing atypical hemangiomas

    July 9, 2003: “unofficial report” from neuroradiologist:  Straight cervical spine, hypermobile intersegmental instability C4-5. posterior central herniation c4-5 larger with extension, herniation at C5-6 to left neural foramina, herniation C6-7 to left neural foramina, larger with extension. C7 nerve root enhancement ? benign neural inflammation ? Herniations smaller with flexion.

    August 28, 2003: second positional Cervical MRI

  • Straight Cervical Spine
  • Hypermobile intersegmental instability C4-5
  • Small midline posterior disc herniation at C4-5, larger on extension, smaller flexion in midline
  • Posterior disc herniation L C5-6 extending into L neural foramen
  • Posterior disc herniation L C6-7 extending into L neural foramen, becomes sl larger on extension and smaller on flexion in the midline
  • Degeneration C5-6, C6-7
  • Lateral subluxation of C6 vertebral body with C6 shifting toward R with reference to C7 vertebra, lessened in the recumbent and flexion kinetic maneuver.
  • Findings more pronounced since June 20, 2003 study as a result of comparative recumbent imaging studies in present examination



    October 8, 2003 CT and cervical spine studies
    Cervical spine results: degenerative disease C5-6-7. Small spurs left side increased encroachment during flexion compared to extension, limited range of motion, no spondylolisthesis
    CT results-small posterior and central disc protrusion C4-5, degenerative disease C5-6/C6-7 with diffuse annular disc bulges and osteophyte formastion, mild encroachment upon neural foramina due to associated uncovertebral joint osteophyte formation

    October 30, 2003: MRI in very specific postitions: head tilting towards left side-very painful in left scapula area, down left arm with increased tingling. Gait feeling unsteady and weak. Pain and arm weakness unchanged.
    Unofficial report: degenerative osteophyte formation C5-6 C6-7 extending into neural foramina.

    December 16,2003 EMG: normal

    December 18, 2003 SSERs: normal

    February 23, 2004: ANA positive, all other lab work negative. Lupus and other auto immune, rheumatologic diseases excluded.

    May 12, 2004 MRI report: thoracic spine - within normal limits, normal signal intensity within the thoracic spinal cord, no sign of injury or demyelination.  Lumbar - mild dengenerative broad annular disc bulges from L3-4 through L5-S1 without central canal or neural foraminal narrowing, no focal disc herniation.  Mild hypertrophic degenerative facet spondylosis.

    May 20, 2004 B&Ws: EMG left arm and leg. Impression -  Left H reflex absent (Leg Study - three attempts to elicit response) while right H reflex present and normal. “Active, ongoing denervation, complex repetitive discharges and chronic reinervation in the form of long units in the pronator teres.  May represent a chronic C7 radiculopathy.  Absent H reflex is non-specific finding of uncertain clinical significance

    June 4, 2004 Cranial MRI: normal

    July 16, 2004 Complete Evoked Potentials, including auditory, visual and bilateral motor of all extremities: all normal.

    September 7, 2004 Laboratory tests pending, including Ceruloplasmin, C-Reactive Protein, Creatine Kinase, Lyme Ab, Paraneoplastic Ab, Purkinje Cell Ab, Protein Electrophoresis, RPR, Vitamin B12, Gliadin Ab, Vitamin E.


    AVI format
    front back
    Sagittal right left

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