Associate Professor Penn State Health Hummelstown, Pennsylvania, United States
Case Diagnosis: Cervical myelopathy secondary to C5-C6 disc protrusion
Case Description: A 35-year-old male presented to PM&R Clinic for concussion evaluation. While at work, he dropped a 200lb sofa which then struck the front of his head without loss of consciousness. Initial workup including CT head and XR neck was non-focal. Complaints included headaches, dizziness, neck pain, and balance difficulty. Examination was significantly notable for only restricted neck range-of-motion (ROM) with pain to palpation at neck/shoulder musculature and difficulty with balance testing. He started Physical Therapy for cervical stabilization, ROM neck/shoulders, myofascial release, and balance. Symptoms persisted and in fact, worsened with PT so MRI cervical spine was ordered which revealed severe cord compression at C5-C6 level from a central/right paracentral disc protrusion. He was referred to neurosurgery and underwent C5-C6 anterior diskectomy and fusion with resultant resolution of symptoms and functional issues.
Discussions: Cervical myelopathy can clinically present as pain, dizziness, headaches, paresthesia, motor weakness, gait disturbance, and later, bowel/bladder incontinence. As in this patient’s case, neurologic examination may be non-focal. Factors that prompted further investigation were his worsening pain and persistent balance issues.
Conclusions: Patients who sustain concussion are at risk of sustaining concomitant neck injuries. Cervical diagnoses, including myelopathy, should be considered in the differential diagnoses.
