Myelopathy in an Orthopedic Patient: Case Presentation | OEP376 - Ortho Eval Pal: Optimizing Orthopedic Evaluations and Management Skills

Episode Transcript
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Speaker 1 (00:00):
Hello everyone and welcome to episode 376 of the
OrthoEvalPal podcast.
I am your host, paul Marquis PT, and today we're going to be
talking about myelopathy in anorthopedic patient.
This is going to be a casepresentation.
Today we'll be discussing arecent patient of mine who
presented with left lowerextremity paresthesia and
difficulty walking walking.

(00:26):
I'll review the evaluationprocess and discuss the
management process.
I'll throw out this patient'spresentation just to kind of
show you how you know wesometimes see scenarios in the
clinic that may just not followa straightforward pattern and
talk about what to do with thosefolks.
But before we get started, I'djust like to mention our
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Welcome back.
So I hear a lot of folks wholisten to the show say that they
enjoy case presentations.
I thought that you might findthis recent patient encounter
interesting.
So here we go.
I have this gentleman who comesinto the clinic and he's
between 45 and 50 years old Idon't have his chart in front of
me because I'm doing this athome and he comes in with the
complaints of significant leftlower extremity paresthesia with

(02:19):
progressive leg weakness.
He has a history of on and offridiculous symptoms.
The last bad episode ofsciatica that he had resolved
really well in physical therapyI believe that was a couple
years ago and he reports thatabout seven to 10 days ago
started to develop this severeleft lower extremity paresthesia

(02:41):
and what he felt like wasprogressive, you know lower
extremity weakness.
So he started using a walkerand comes in with that walker
today and is very dependent onit, like he's utilizing his arms
quite a bit, and he states thatthis happened really quickly.
So this isn't something thatwas like real progressive but

(03:02):
kind of hit him hard.
When asked about his upperextremities, he says that
they're really not bothering him.
All right.
I asked him then about hisparesthesia pattern and he says
it's pretty much the whole leg.
And I asked him about, you know, saddle paresthesia and he said
that was significantly worse inthe last couple of days but
doesn't complain of anysignificant bowel or bladder

(03:23):
incontinence issues or retentionproblems or anything like that.
No real changes there.
So he had an MRI of his lumbarspine which showed a herniated
disc at one level and I can'tremember if it was L4, l5, but
there was some sign of bilateralforaminal stenosis which is

(03:43):
actually worse on the left sidethan the left and worse on the
right side than the left.
Now he stated also that hisparesthesias kind of move from
side to side periodically.
He doesn't report being sicklately or having gone out of the
country or somewhere where hecould have, you know, gotten
something or received somethingthat would have caused, you know

(04:05):
, gotten something or receivedsomething that would have caused
, you know, a virus or a feveror anything like that.
So I started with my evaluationto find that I always start with
reflexes pretty much, and so Idid his L4 and S1 reflexes
bilaterally and they were allhyper reflexive.
So whenever I see that, I thinkto myself well, there are

(04:27):
certain diagnoses you know,lower than the thoracic spine
that can cause hyper reflexia.
So maybe we should go to theupper extremities and as I do
that, I do c5, c6 and c7.
They are hyper reflexivebilaterally also.
So now we have a differentpicture.
We have to be thinking upstreama little bit more at some sort

(04:50):
of an upper motor neuron lesiontype issue.
Now there are some people whoare naturally hyper reflexive
all the way around and I've seenthis.
But we need to be thinking isthere something else that could
be going on here to be hyperreflexive, both upper and lower?
So we need to be thinking isthere some sort of a cervical
spine cord lesion?
Does he have a thyroidcondition?

(05:11):
Does he have ALS, ms, some sortof neurodegenerative disorder.
Is this viral?
Does he have a transversemyelitis type of issue?
Does he have some sort of abrain lesion?
So I asked him did you everhave a significant traumatic
brain injury at one point in thepast?
And the answer was no.

(05:33):
So the next thing I do is somesensory testing, and this is
really all over the place.
He has significant loss ofsensation, more so on the left
side than the right.
Upper extremities were notsignificant in regards to
altered sensation one side overthe other at this time.
So then I jump into some manualmuscle testing and to my

(05:54):
surprise, I only find a coupleareas of weakness, and one of
them was in his left triceps.
So I'm now thinking does hehave some sort of a cervical
myeloradiculopathy at C7 maybe?
And then I also test hisextensor hallucis longus to find

(06:14):
that that is weak on the leftside also.
Now, interestingly enough,you'd think that he would have
some quadricep weakness, hipflexor weakness, calf weakness,
something like that, because ofwhat he feels is his legs giving
out, or his leg weakness whichrequires him to use a walker.

Speaker 2 (06:33):
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Speaker 1 (07:12):
He states he doesn't think it's really weakness but
that he has no idea where hislegs are.
So he has loss of positionalawareness of his legs.
So now we need to be thinkingmore.
You know, neurologicalobviously.
So I do a Hoffman's test and heis positive on the left side,
not on the right side.
He does have some mild clonuson one ankle and I can't really

(07:37):
remember which side it was on,to be honest with you, but
nonetheless there was some mildclonus that was there.
So again we're thinking uppermotor neuron lesion here.
I did a Babinski test on bothsides but I wasn't able to get a
real good test.
He actually found this to bequite ticklish and was kind of
pulling back, but didn't havethe typical upgoing of the toes

(07:59):
which happens kind of after thestroke when you have somebody
with an upper motor neuronlesion.
So I'm throwing that one outthe window.
His toes were not going down,going either.
So then I placed him on thetable and I tried.
I tested his tricep strength orI had another therapist test
his tricep strength to find thatit was, you know, weak.

(08:20):
It was about four over five andI tractioned him to find no
improvement with his tricepstrength.
So had he had some, you know,nerve root compression or maybe
some significant foraminalencroachment at c7?
You usually see an improvementin the tricep strength when you
traction the neck and retest thestrength.

(08:41):
So didn't see anything there.
So at this stage of the gameI'm very concerned.
His weakness, I mean hisbalance, is progressively
getting worse, significantamount of paresthesias which
kind of move around and he hassome signs of upper motor neuron
lesion with a positiveHoffman's and hyperreflexia and

(09:02):
altered sensation and saddleparesthesia.
So I am holding off on physicaltherapy on this guy.
I call his provider who wasvery suspicious of this also and
as a result she had ordered anMRI of his thoracic spine and
neck and come to find out he didhave some lesions in his neck

(09:25):
and even in his brainstem,indicative of MS.
So they ordered an MRI of hisbrain stat and come to find out
had some lesions there also.
Find out, had some lesionsthere also.
So I guess at this point thefindings are driving in the
direction of MS.
But there are other scenariosthat can look like this, some

(09:48):
viral issues and whatnot.
So apparently he was admittedand given a high dose of
steroids.
I haven't seen him since.
Now, I am not a neurologist, I'ma physical therapist.
I don't even have my DPT ormaster's degree.
I graduated way before allthose things existed and so what
I'm trying to say here is thatthe reason I brought this

(10:13):
patient situation up is to letyou know that you don't need to
treat every single patient whocomes into your clinic.
Okay, um, I communicate withthe patient's provider.
We both agree that there wassomething more than just a
sciatica type of situation hereand that sometimes just
recognizing something uh is isall you need to do, and and and

(10:35):
giving this patient a differentdirection, sending them to a
specialist, a neurologist,physiatrist, somebody who
understands us better and canmanage it better, can prescribe
the right medication, maybeorder other diagnostic tests to
help localize this lesion alittle bit more and manage it
more efficiently.
Okay, so we could have, youknow, worked on balance.

(10:56):
We could have worked on somestrengthening.
So we could have, you know,worked on balance.
We could have worked on somestrengthening activities.
We could have worked onflexibility and a bunch of other
stuff, but I think reallyexpediting this patient to other
services was the way to go inthis situation, and
unfortunately, I do see a lot ofpatients in this situation, for
somebody who primarily seesorthopedic and sports patients,

(11:16):
and so I think it's important torecognize when something
doesn't look right, to kind ofmanage it and not just try to
treat it.
So I will add some links in theshow notes today, including some
patients who have myelopathicsymptoms, everything from
somebody who has ahyperthyroidism to people who
have some spinal cord issues.

(11:36):
They're quite.
Some of these may be quite old,okay, so don't be surprised.
I didn't have high def camerasway back when I started on
YouTube, but you can still get agood idea of what these look
like and what they present like.
So I hope you enjoyed today'sshow and that you all have a
great day.
If you have questions for me,feel free to send them Questions

(11:57):
that you'd like me to put onthe show.
I'm more than happy to do that,all right.
So be kind to each other andtake care.

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Myelopathy in an Orthopedic Patient: Case Presentation | OEP376

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.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}Myelopathy in an Orthopedic Patient: Case Presentation | OEP376