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464 - Severe Bilateral C5/6 Radiculopathies Mimicking Polymyalgia Rheumatica: The Dangers of Delayed Diagnosis

Thursday, February 27, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

WS

William Schultze, DO

Resident Physician
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania, United States

Co-Author(s)

JC

Jesse Champi, MD

Resident Physician
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania, United States
CS

Catherine Stauffer, MD, MS

Resident Physician
UPMC
Pittsburgh, Pennsylvania, United States
Michael C. C. Munin, MD

Attending Physician
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania, United States

Case Diagnosis: Severe Bilateral C5/C6 Cervical Radiculopathies

Case Description: An independent 64-year-old male presented to his primary care provider with painless weakness and stiffness of his shoulders for 3 months, with examination notable for limited abduction to 90 degrees. Laboratory evaluation revealed borderline elevated inflammatory markers, and the patient was prescribed physical therapy and high-dose prednisone for presumed polymyalgia rheumatica (PMR). At 3-month follow-up, he reported modest improvement with continued steroid use, however physical examination revealed worsened shoulder abduction limited to 45 degrees. An EMG was subsequently ordered, which revealed severe chronic bilateral C5/C6 cervical radiculopathies. Magnetic resonance imaging confirmed severe canal and foraminal stenosis at C4-C5 and C5-C6, with myelomalacia at C6, requiring C3-C7 posterior cervical decompression and fusion. Post-operatively, he completed 4 weeks of inpatient rehabilitation with minimal improvement in his upper extremity weakness, and was ultimately discharged to a skilled nursing facility with impairments in activities of daily living.

Discussions: The differential diagnosis for symmetric shoulder girdle weakness could include inflammatory conditions such as PMR, but neurologic conditions such as bilateral cervical radiculopathy, bilateral upper trunk plexopathy, or myopathy should have been included. Evaluation with laboratory, electrodiagnostic, and radiologic data is critical to prevent long-term function loss. This patient’s inflammatory markers were normal when age-adjusted, making PMR less likely. Furthermore, steroids may improve symptoms related to nerve or muscle inflammation, which would not narrow the differential diagnosis. Expedited radiologic or electrodiagnostic evaluation would have provided definitive evidence of correctable cervical cord and root compression.

Conclusions: This case of severe chronic bilateral C5/C6 radiculopathies with central cord compression was initially misdiagnosed as PMR, resulting in drastic loss of function due to a 9-month delay in electrodiagnostic and radiologic workup. Physiatrists must be able to diagnose a broad range of nerve and muscle pathologies to ensure accurate diagnosis and prevent long-term disability.