225 - A Case Of Chronic Left-Sided Neck Pain With Weakness And Hyperreflexia

Multiple sclerosis with superimposed severe cervical stenosis

 

Case Description:

A 55-year-old Hispanic male with a history of C5-C6 disc herniation and severe foraminal narrowing presented with chronic left-sided weakness and neck pain. The pain was constant and had nonspecific radicular symptoms from the neck to his fingertips. He recently began to develop increasing gait instability. The patient denied any history of falls, exacerbating factors, incontinence, fevers, or chills. He experienced minimal improvement with gabapentin and naproxen. Previous EMG was negative.

On examination, he had diminished left-sided motor strength, with 4/5 in finger flexion, 3/5 in finger abduction, 4/5 in hip flexion, and 2/5 in dorsiflexion. Left-sided reflexes were 3+ throughout with elicited clonus. Left-sided sensation to pinprick was decreased. Spurling's test was negative. Diagnostic testing displayed nonspecific periventricular and subcortical white matter changes on MRI Brain and Lumbar puncture showed positive oligoclonal bands, suggestive of multiple sclerosis.

Discussions: Although this patient presents with classic radicular symptoms, it is important to keep other neurologic conditions in the differential due to his left-sided weakness with hyperreflexia. Potential etiologies may include stroke, spinal cord injury, or demyelinating conditions. The presence of periventricular and subcortical white matter changes on brain MRI and oligoclonal bands on lumbar puncture strongly supports the diagnosis of multiple sclerosis (MS) in this patient. MS has a strong female predominance and is seen mostly in Caucasians, making this case of Hispanic male with MS more difficult to identify.

Conclusions: Though a diagnosis like cervical stenosis is more commonly seen within our patient population, this case highlights the importance of maintaining a broad differential diagnosis with a complete, thorough workup.