Nancy Tian, MD
Resident Physician
The Ohio State University Physical Medicine and Rehabilitation
Columbus, Ohio, United States
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Timothy S. Hake, MD
Dodd Rehabilitation Hospital Medical Director
The Ohio State University Physical Medicine and Rehabilitation
Columbus OH, Ohio, United States
Karan Arul, MD
Resident Physician
The Ohio State University Physical Medicine and Rehabilitation
Columbus, Ohio, United States
C2 fracture with severe stenosis and myelopathy misdiagnosed as functional neurologic disorder (FND).
Case Description:
An 86-year-old male with anxiety and depression admitted to inpatient rehabilitation (IPR) after being diagnosed with FND. Initially presented to acute care with several months of progressive weakness, numbness, and decreased hand dexterity. MRI brain was unremarkable. He was diagnosed with FND by Psychiatry due to an inconsistent exam and negative brain imaging. At IPR, physical exam was significant for cervical tenderness, dysmetria, dysdiadochokinesia, impaired hand sensation, and decreased finger flexion strength. With therapies, he demonstrated upper limb weakness, impaired ADLs and postural instability with a right lateral lean that impacted mobility. Cervical MRI showed C2 fracture with severe central stenosis and cord compression. He underwent a C2 laminectomy and occiput-C3 fusion by Orthopedic surgery.
Discussions:
FND is a condition in which the central nervous system misinterprets stressors, resulting in neurologic manifestations of symptoms without identifiable anatomic etiology. Onset is typically 40-years-old(1). Symptoms are inconsistent, varying throughout the day, or with different activities. Physical exam findings may not localize anatomically. Patients often have comorbid psychiatric diagnoses and significant stressors before onset. However, FND is a diagnosis of exclusion. In this patient, there were confounders that superficially fit FND. In particular, he had psychiatric diagnoses, symptom onset after his wife passed away, and rapid progression of symptoms after transition to assisted living. However, his exam consistently demonstrated cervical tenderness, proprioceptive deficits, and decreased hand dexterity, prompting evaluation of cervical pathology.
Conclusions:
FND can only be diagnosed if symptoms are not better explained by a medical or mental disorder. Even with confounding factors such as multiple psychiatric disorders and symptom onset after significant stressors, those that have physical exam findings consistent with central nervous system deficits warrant further evaluation. This case demonstrates the benefit of a multidisciplinary approach in diagnosing FND.
