1125 - Severe Thoracic Myelopathy Identified Through Physical Exam Following Non-Diagnostic Imaging

Case Diagnosis: Compressive Thoracic Myelopathy

Case Description: 71-year-old male with a PMH of chronic lower back pain presented to ED with bilateral lower extremity radicular pain and spasms. CT lumbar spine demonstrated degenerative changes in thoracic and lumbar regions, partial fusion of L2-L3, and possible lumbar spinal stenosis. The patient was discharged after observation. Symptoms progressively worsened and patient developed urinary and defecation urgency. PCP subsequently provided prednisone and tizanidine, offering partial symptomatic relief. MRI lumbar spine confirmed previous CT findings. We assessed the patient and physical exam revealed significant weakness, spasticity, increased tone, and persistent spasms in the lower extremities, concerning for upper motor neuron lesion. Upon further review of the patient`s lumbar MRI, at the superior border of the film an irregularity and narrowing of the thecal sac on T2-weighted imaging was noted. STAT thoracic spine MRI was obtained and demonstrated severe central canal stenosis with abnormal cord signal at T10-T11.

Discussions: In this case, the patient`s symptoms and imaging led clinicians to attribute his condition to lumbar spinal stenosis and degenerative disk disease, prompting conservative management. However, severe compressive cord disease is a medical emergency and needs to be decompressed urgently to avoid long term defects. With the employment of thorough physical examination, upper motor neuron signs were found and enabled us to take appropriate steps to determine the diagnosis. STAT imaging of the thoracic spine confirming the existing thoracic myelopathy, allowing the patient to receive emergency decompression.

Conclusions: This case highlights the importance for physiatrists to utilize a comprehensive physical exam in the diagnostic workup of acute back pain. Upper motor neuron signs on the physical exam were crucial in raising concern for cord compression in the setting of initial non-diagnostic imaging.