630 - Cervical Myelopathy: Differentiating Hoofbeats in a Herd of Ordinary Horses

Case Diagnosis: 45-year old female with history of bilateral carpal tunnel release, right ulnar neuritis, with worsening hand paresthesias and weakness following elbow bursectomy, found ultimately to have cervical myelopathy prior to planned ulnar transposition surgery.

Case Description:

Patient presented to physiatry clinic for primarily right upper extremity pain and paresthesias. She was initially evaluated in hand surgery clinic where she has previously undergone bilateral carpal tunnel release surgeries and right elbow bursectomy, and she was planned for right ulnar nerve transposition based on ultrasound evidence of ulnar neuritis at the elbow. Additionally, ultrasound showed dynamic left axillary vein narrowing suggesting thoracic outlet syndrome. NCS/EMG of upper extremities were normal.

Exam showed weakness in right EIP, FDS, FDP, and triceps. Sensation was diminished to light touch in C5-C6 distributions and in the palmar hand/digits. Reflexes were intact except for an absent right triceps reflex.

Since the clinical presentation did not clearly match the above established diagnoses, cervical MRI was performed, which revealed severe canal stenosis and signal change at C3-4. Patient was urgently referred to neurosurgery and underwent C3-5 anterior discectomy and fusion.

Discussions: Median/ulnar neuropathy, TOS, and cervical myelopathy are common causes of upper extremity dysesthesias. Confirmation bias from medical history and prior evaluations can mislead diagnosis and treatment decisions without holistic interpretation of all exam and diagnostic findings. This case had multiple confounding factors, including inconsistent EMG results and multiple positive imaging, but ultimately, thorough history and examination were key factors in diagnosing cervical myelopathy.

Conclusions: This patient was scheduled for a surgery to treat a diagnosis, which, in this case, was a red herring, and her course was positively impacted by a thorough neuromuscular evaluation. This case highlights the importance of a strong musculoskeletal and neurologic knowledge base inherent to PM&R.