Grand Case Report

MYELOPATHY

Presented by:
Wahyu Permata Lisa. S
NIM : 1708435968

Supervisor:
dr. Yossy Maryanti, Sp.S, M.Biomed.

CLINICAL CLERKSHIP
NEUROLOGY DEPARTEMENT
FACULTY OF MEDICINE RIAU UNIVERSITYOF RIAU
ARIFIN ACHMAD GENERAL HOSPITAL
PEKANBARU
2019
 KEMENTRIAN PENDIDIKAN DAN KEBUDAYAAN
FAKULTAS KEDOKTERAN UNIVERSITAS RIAU
SMF/ BAGIAN SARAF
Sekretariat : Gedung Kelas 03, RSUD Arifin Achmad Lantai 04
Jl. Mustika, Telp. 0761-7894000
E-mail : saraffkur@gmail.com
PEKANBARU

I. Patient’s Identity

Name Ms. SE
Age 20 years
Gender Female
Address Pekanbaru
Religion Moeslem
Marital’s Status Not Married
Occupation Not Worked
Entry Hospital February, 28th 2019
Medical Record 005355xx

II ANAMNESIS :
Auto & Alloanamnesis (February, 28th 2019)
A. Chief Complain
Weakness on both arm and leg that more severe since 10 days before admitted
to the hospital.

B. Present illness history

10 days before admitted to the hospital, the patient has complained the weakness
of arm and leg. Weakness began numbness on both of the leg and occur gradually.
Previously the patient couldn’t moved her legs and always walked slowly by
dragged her legs. But now, the patient couldn’t be lifted and moved both of the leg
and just had a bed rest. The patient also has complained on her arm, the arm felt
heavy but the patient could to lifted her arm and hold the object previously. But, in
this time she felt difficult to hold the object example to hold the pen to write. The
patient felt her arm doesn’t has a power to do it. The patient has complaint in
controlling her urination. She felt not satified after miksi. But, she could know if
she want to miksi. There is no complaint of controlling her defecation. Fever was
denied, weight loss denied, prolonged cough denied, and history of trauma was
denied.
1 months before admitted to the hospital, patients complained pain in his neck
and radiating to her shoulder and arm intermittently. Pain felt when woke up in the
morning and will decrease with a rest, it occured suddenly without any previous
trauma histories before.
8 years before admitted to the hospital, its the first time the patient has
complained difficult to walked because of weakness on both legs. Although
difficult to walked, patient still moved the legs. The patient could take care of
herself and do some activity in her house. The patient also has a complained in her
arm. Firstly she felt tingled in her arm, but she still do daily activity. Because of the
complained she go to a physioteraphy and do the exercise for 5 yeras. But the
complained couldn’t decrease. After that, the patient decided to stopped the
physioteraphy.

C. Past Illness history

 Cough produced phlegm (-)
 Bump on the back (-)
 Weight loss and appetite (-)
 A history of 6 months medication (-)
 Hypertension (-), Diabetes mellitus (-)
 A history of Cancer (-)
 History of backbone surgery (-)

D. Family Illness History

 A history of TB (-)
 A history of Cancer (-)
RESUME ANAMNESIS

Ms. SE, 20 years old admitted to the hospital on February, 28th 2019 with chief
complained the weakness of arm and leg that more severe since 10 days before
admission. Because of that the patient couldn’t be lifted and moved both of the leg
and arm, couldn’t do anything and just had a bed rest. The patient also complained
pain in the neck when woke up, and the pain radiating to her shoulder and arm
intermittently since about 1 months before admission. Previously the patient had a
phisioteraphy since 8 years ago.

III. PHYSICAL EXAMINATION

A. Generalized Condition
Blood Presure : 100/80 mmHg
Heart Rate : 82 bpm
Respiratory : Respiratory rate : 20 x/mnt Type : torakoabdominal
Temperature : 36,3°C
Weight : 40 kg Height : 150 cm
IMT : 17,77

B. Neurological status
1) Consciousness : Composmentis GCS : 15 (E4V5 M6)
2) Cognitive Function : Normal
3) Neck Rigidity : Negative

C. Cranial Nerves
1. N. I (Olfactorius )
Right Left Interpretation
Sense of Smell Normal Normal Normal
2. N.II (Opticus)
Right Left Interpretation
Visual Acuity Normal Normal
Normal
Visual Fields Normal Normal
Colour Recognition Normal Normal

3. N.III (Oculomotorius)
Right Left Interpretation
Ptosis (-) (-)
Pupil
Shape Round Round
Side Φ3mm Φ3mm Normal
Extraocular movement Normal Normal
Pupillary reaction to light
Direct + +
Indirect + +

4. N. IV (Trokhlearis)
Right Left Interpretation
Extraocular movement Normal Normal Normal

5. N. V (Trigeminus)
Right Left Interpretation
Motoric Normal Normal
Sensory Normal Normal Normal
Corneal reflex (+) (+)

6. N. VI (Abduscens)
Right Left Interpretation
Extraocular movement Normal Normal Normal
 Strabismus (-) (-)
Deviation (-) (-)

7. N. VII (Facialis)
Right Left Interpretation
Tic (-) (-)
Motoric Normal Normal
Normal
Flavour Sense Normal Normal
Tanda chvostek - -

8. N. VIII (Acusticus)
Right Left Interpretation

Hearing sense Normal Normal Normal

9. N. IX (Glossopharyngeus)
Right Left Interpretation
Arkus farings Normal Normal
Flavour sense Normal Normal Normal
Gag Reflex (+) (+)

10. N. X (Vagus)
Right Left Interpretation
Arcus farings Normal Normal
Normal
Dysfonia (-) (-)

11. N. XI (Accesorius)
Right Left Interpretation
Motoric Normal Normal
Normal
Trofi Eutrofi Eutrofi
 12. N. XII (Hypoglossus)
Right Left Interpretation
Motoric Normal Normal
Trofi Eutrofi Eutrofi Normal
Tremor (-) (-)
Disartria (-) (-)

D. Motoric
Right Left Interpretation
Upper Extremity
Strength
Distal 2 2
Proximal 2 2
Tone Spastik Spastik
Trophy Atrophy Atrophy
Involuntary movements (-) (-)
Clonus (+) (+)
Tetraparese
Lower Extremity (UMN Type)
Strength
Distal 1 1
Proximal 1 1
Tone Spastik Spastik
Trophy Atrophy Atrophy
Involuntary movements (-) (-)
Clonus (+) (+)
Body
Trophy Eutrophy Eutrophy
Involuntary movements (-) (-) Normal
Abdominal Reflex (-) (-)

E. Sensory
Right Left Interpretation
Touch ↓ on C1-2 ↓ on C1-2 Hypesthesia on
Pain ↓ on C1-2 ↓ on C1-2 high as C1-C2
Temperature Not identified Not identified dermatome
Propioseptive Negative Negative
F. Reflex
Right Left Interpretation
Physiologic
Biceps (+++) (+++)
Triceps (++) (++) Physiologic reflex ()
Knee (+++) (+++)
Ankle (++) (++)
Pathologic
Babinsky (+) (+)
Chaddock (+) (+)
Hoffman Tromer (+) (+)
Openheim (-) (-) Pathologic reflex (+)
Schaefer (-) (-)
Gordon (-) (-)
Primitive Reflex
Palmomental (-) (-) No Primitive Reflex
Snout (-) (-)

G. Coordination
Right Left Interpretation
Point to point movements Normal Normal
Walk heel to toe Not Tested Not Tested
Difficult to assessed
Gait Not Tested Not Tested
Tandem Not Tested Not Tested
Romberg Not Tested Not Tested

H. Autonom system
Urination : Urine catheterized
Defecation : Normal
Sweat : Normal

I. Others Examination
a. Laseque : >700
b. Kernig : >1300
c. Patrick : -/-
d. Kontrapatrick : -/-
e. Valsava test : -
f. Brudzinski : -
 g. Spurling test :
h. Head Traction :
i. Valsava test :

EXAMINATION RESUME
General Status :
 Blood Pressure 100/80 mmHg
 Heart Rate 82 bpm
 Respiratory Rate 20 times per minute
 Temperature 36,3°C

Noble Function : Normal

Neck Stiffness : Negative
Cranial Nerves : Normal
Motoric : Tetraparese (UMN Type)
Sensory : Hypesthesia on high as C1-C2 dermatome to the lower
Coordination : Difficult to assessed
Autonomy : Abnormal urination
Reflex : Physiologic reflex () Patologic reflex (+)

IV. WORKING DIAGNOSIS

CLINICAL DIAGNOSIS : Cervical Myelopathy
 Tetraparese (UMN Type)
 Hypesthesia on high as C1-C2 dermatome to the lower
 Abnormal urination
TOPICAL DIAGNOSIS : 1st- 2nd cervical spinal cord segments
ETIOLOGICAL DIAGNOSIS : Cervical Mielopathy ec suspect
Spondylosis
DIFFERENTIAL DIAGNOSIS : Susp. Spondilitis TB

V. SUGGESTION EXAMINATION :
 Blood routine
  Blood chemistry
 MRI cervical spine non contrast and with contrast
VI. MANAGEMENT
 Maintanance : IVFD NaCl 0,9% 20 dpm
 Anti inflamation : Methylprednisolone 3 x 125 mg per IV
• Gastric Protector : Ranitidine 2 x 50 mg IV
 Neurotropic : Mecobalamin 3 x 500 mg

VIII. LABORATORY AND RADIOLOGY FINDINGS

1. Blood Routine
Hb : 7,9 g /dl WBC : 5030
Ht : 26,4 % PLT : 386.000

2. Blood Chemistry
- Ureum : 26 mg/dL
- Creatinin : 0,60 mg/dL
- AST : 15 U/L
- ALT : 9 U/L

3. Electrolyte
- Na : 142 mmol/L
- K : 4,0 mmol/L
- Cl : 101 mmol/L
 MRI cervical spine non contrast and with contrast
(February, 26th 2019)

Result :
 Stenosis of canalis spinalis on C1-2 with compression of spinal cord
because of suspect spondylosis.
 Suspect edema spinal cord on C1-2
Follow up March, 1st 2019
Subjective :
Weakness both on legs and arms, neck pain (+), fever (-), defecation (+).
Objective :
GCS : 15
Blood Pressure : 110/80 mmHg
Heart Rate : 80 bpm
Respiratory rate : 20 tpm
Temperature : 38 °C
Cognitive fungtion : Normal
Neck Stiffness : Negative
Cranial Nerves : Normal
Motoric : Tetraparase (UMN Type)
2 2
1 1
Sensory : Hypesthesia on C2 dermatome
Coordination : Difficult to assessed
Autonomy : Abnormal Urination
Reflex : Physiologic reflex ()
Pathologic reflex (+)
Assessment :
Cervical myelopathy ec suspect spondylosis
Plan :
 Maintanance : IVFD NaCl 0,9% 20 dpm
 Anti inflamation : Methylprednisolone 3 x 125 mg per IV
 Gastric Protector : Ranitidine 2 x 50 mg per IV
 Neurotropic : Mecobalamin 3 x 500 mg
 DISCUSSION

1. Cervical spondylotic myelopathy (CSM)

1.1 Definition
Cervical spondylotic myelopathy is the most serious consequence of
cervical intervertebral disk degeneration, especially when it is associated with a
narrow cervical vertebral canal.1

1.2 Epidemiology
Cervical spondylosis myelopathy can be identified in the majority of people
older than 40 years. But sometimes it can identified in the patient younger than 40
years. In Asia especially Taiwan has a data overall incidence of CSM-related
hospitalization was 4.04 per 100,000 person-years. Specifically, males and older
persons had a higher incidence rate of CSM.2

1.3 Classification
Cervical Spondylosis Mielopathy divided to 5 type , there are anterior lesion
syndrome (Type I), which involved unilateral upper extremity disturbance, was
found in 13.1% of patient. Type II (central lesion syndrome), which involved
bilateral upper extremity disturbance, was found in 8.6% of patient. Posterior lesion
syndrome (Type III), which involved bilateral lower extremity disfunction typically
in combination with an ataxic gait, was seen in 5.4% of patient. Hemilateral lesion
syndrome (Type IV) was characterized by hemilateral motor disturbance, with or
without dissociated sensory disturbance. It included both typical and atypical
Brown-Séquard syndrome. The prevalence of this type was 12.1%. The most
common type of cervical myelopathy was transverse lesion syndrome (Type V),
which accounted for 60.7% of our myelopathy patient.. The classification on the
table 2.3
Table 2. Classification of cervical spondylosis mielophaty

1.4 Clinical Manifestation

CSM may present with divergent clinical findings depending on the levels
affected, involvement of the neural foramina, and long tract involvement. A variety
of neurological signs and symptoms may be present, including sensory changes,
reflex abnormalities, decreased dexterity, weakness, gait instability, bowel and
bladder dysfunction, spasticity, presence of Hoffman’s and/or Babinski’s sign, axial
neck pain, radiculopathy, and even acute spinal cord injury. The variation in
symptoms caused by involvement of the various cervical levels results in a large
possibility of clinical presentations affecting almost any muscle of the body.3
CSM on upper motor neuron findings such as spasticity, hyperreflexia,
clonus, Babinski, and even bowel and bladder dysfunction may also be present.
These findings often occur together with lower motor neuron findings, such as
hyporreflexia and atrophy in the upper extremities. Numbness or paresthesias in the
upper extremities is usually nonspecific, although dermatomal sensory complaints
can occur from a coexisting radiculopathy. Sensory changes in the lower
extremities is also common and typically involve the dorsal columns. Furthermore,
motor weakness as well as gait impairment, are also commonly present Severity of
symptoms, functional impairment, and progression of symptoms rather than clinical
syndrome classification drive decision-making for therapeutic interventions.3,4
Conclusion of the clinical manifestation on the table 3.

Table 3 Clinical manifestation of cervical spondylosis mielophaty5

1.5 Diagnosis
In addition to history and physical examination, diagnosis of cervical
spondylosis mielopathy of the spinal cord can be enforced with the help of
investigations radiograph, which may demonstrate osteophyte formation, kyphosis,
and even subluxation. Nevertheless, magnetic resonance imaging (MRI) of the
cervical spine still remains the most useful diagnostic tool. In addition to providing
an evaluation of the spinal cord, the ligaments, and the intervertebral discs, MRI
may also help to rule out other differential’ diagnoses, such as spinal cord tumors
or syrinx. Furthermore, T2-weighted hyperintensity at the level of spinal
compression has also been shown to correlate with CSM severity and has been
supposed to be an important prognostic factor. Such findings are thought to
represent edema and inflammation. On the other hand T1-hypointensity has been
shown to be a more severe sign, representing ischemia, myelomalacia, or gliosis as
has been correlated with postoperative worst outcome.4

1.6 Management
Conservative treatments for CSM often include neck immobilization,
pharmacologic treatments, lifestyle modifications, and physical modalities. There
is a lack of high-level studies comparing these modalities to surgical intervention.
Therefore, conservative therapies are often initiated based on a clinician’s
preference or specialty.5
The surgical indications for cervical myelopathy is identified several poor
prognostic factors with conservative treatment, which included the progression of
symptoms, presence of myelopathy for more than 6 months, compression ratio
approaching 0.4 (indicating flattening of the cord), transverse area of the cord and
with progressive neurologic deficits.1,5

2. Cervical Root Syndrome

2.1 Definition
Cervical root syndrome or Cervical radiculopathy is a dysfunction of a nerve
root of the cervical spine. The seventh (60%) and sixth (25%) cervical nerve roots
are the most commonly affected. In the younger population, cervical radiculopathy
is a result of a disc herniation or an acute injury causing foraminal impingement of
an exiting nerve. Disc herniation accounts for 20-25% of the cases of cervical
radiculopathy. In the older patient, cervical radiculopathy is often a result of
foraminal narrowing from osteophyte formation, decreased disc height,
degenerative changes of the uncovertebral joints anteriorly and of the facet joins
posteriorly.Factors associated with increased risk include heavy manual labor,
smoking, driving and operating vibrating equipment. 6

2.2 Clinical Manifestation

Cervical radiculopathy produce some characteristic manifestation such as:
pain and sensory deficit in the corresponding dermatome; greater impairment of
pain sensation than of the other sensory modalities; reduced strength in segment-
indicating muscles and rarely muscle atrophy; reflex deficits corresponding to the
damaged roots; absense of autonomic deficits in the limbs.7
Individual cervical radiculopathy syndrome are characterized by the
following deficits as in table 2.8

2.3 Diagnosis
Obtaining a detailed history and physical examination is important to
establish a diagnosis of cervical root syndrome or cervical radiculopathy. Detailed
history about chief complaint (pain, numbness, weakness, location of symptoms),
what activities and head positions increase of decrease symptoms, when did the
injury occur (include the mechanism of injury), previous similar symptoms,
changes in gait, bowel or bladder dysfunction, sensory changes, and previous
treatment. 6
Physical examination begins with observation of the patient (typically,
patients tilt their head away from the side of injury and hold their neck stiffly),
active Range of Motion (ROM) is usually reduced. After we observe the patient we
do palpate their muscles (tenderness, hypotonic, hypertonic), check for the motoric
function, sensoric function, physiologic and pathologic reflexes. Provocative tests
are also useful to diagnose cervical radiculopathy such as:6
a. Spurling Test
Also called the foraminal compression tes tis probably the best test for
confirming the diagnosis of cervical radiculopathy. It is performed by
 positioning the patient with the neck extended and the head rotated, and
then applying downward pressure on the head. The test is considered
positive if pain radiates into the limb ipsilateral to the side to which the
head is rotated. The Spurling test has been found to be very specific
(93%), but not sensitive (30%), in diagnosing acute radiculopathy.
b. Manual cervical distraction test
Manual cervical distraction can be used as a physical examination test.
With the patient in a supine position, gentle manual distraction often
greatly reduces the neck and limb symptoms in patients with
radiculopathy.
c. Lhermitte sign
Lhermitte sign is an electric shock-like sensation radiating down the
spine, and in some patients into the extremities, elicited by flexion of
the neck. This sign has been found in patients with cervical cord
involvement or cervical spondylosis, and also in patients with tumor
and multiple sclerosis (MS); however, the Lhermitte sign should be
negative in those with cervical radiculopathy. Manual distraction may
reduce the neck and limb symptoms in patients with cervical
radiculopathy.
THE BASIC OF DIAGNOSIS

1. Basic clinical diagnose

According to anamnesis and physical examination, we have found this
patient has tetraparese (UMN Type), hypesthesia on C2 dermatome to the lower.
The several important things above mean that there is damaging on spinal cord.

2. Basic topic diagnose

Based on anamnesis there are weakness on both of legs and arm and from
the examination of sensory system, we found hypoesthesia from C2 dermatome to
the lowe. Based on the dermatomes, we found that the level of disorder is 2nd
cervical spinal cord segments.

3. Basic etiological diagnose

Basic etiological diagnose of this patient lead to cervical spondylosis
mielophaty because based on anamnesis and physical examination, we have found
symptoms like localized neck pain, weakness on both leg and arm. These symptoms
were gradually occur. This classic features suitable which is a chronic progressive
disease.
Based on result from MRI examination there is stenosis canalis spinalis on
C1-2 with compression of spinal cord because of suspect spondylosis.

4. Basic differential diagnosis

Spinal cord tumour is chosen as the differential diagnose because it almost
have the same manifestation, it starting from the pain than sensory disturbance and
motor disturbance. The needs for investigations to establish a tumor diagnostic.

5. Basic Workup
- Laboratory : to know the risk factors whether the infection exis and
knowing the general condition of the patient for therapeutic purpose.
 - Thoracal MRI : to find the etiologic for this case at spinal cord area or
vertebrae.

6. Basic final diagnose

The final diagnose of this patient is cervical spondylosis mielophaty. This
diagnose is considered by history taking, general and neurological examination and
adjunct examination. From history taking, we have found symptoms like neck pain
radiculating until to the sholder, and weakness of all extremity. From physical
examination there was tetraparese with UMN type, hypesthesia on C2 dermatome.
From MRI’s result there is stenosis canalis spinalis on C1-2 with compression of
spinal cord because of suspect spondylosis.

7. Basic treatment

a. The aim of IVFD NaCl 0,9% 20 dpm is to maintain the euvolemic condition
b. The aim of Metilprednisolon 3x125 mg per IV to provide relief for inflamed
areas of the body.
c. The aim of Mecobalamin 3 x 500 mg as a neurotropic
d. The aim of Ranitidine 2 x 50 mg IV to preventing side effects from the use
of methylprednisolone in the stomach in the form of peptic ulcer
 REFERENCE

1. Cai Z, Zhang N, Ma N, Dong G, Wang S, Zhaou Y. Trend of Incidence of

Cervical Spondylosis: decerase with aging in the elderly and increase with
aging in the young and the adult. Int J Clin Exp Med. 2016;9(7):14329-14336
2. Mihara H, Tatara Y, Nimmura T, Tatara Y. Novel Classification System of
Cervical Myelopathy Based on Symptomatology. iMedPub. 2018; 9(6): 1-6
3. Yarbrough CK, Murphy RK, Ray WZ, Stewart TJ. The Natural History and
Clinical Presentation of Cervical Spondylotic Myelopathy. Hindawi Publishing
Corporation. 2012: 1-4
4. Mattei TA, Goulart CR, Milano JB, Dutra LP, Fasset DR. Cervical Spondylotic
Myelopathy: Pathophysiology, Diagnosis, and Surgical Techniques. ISRN
Neurology. 2011: 1-5
5. Bakhsheshian J, Mekhta VA, Liu JC. Current Diagnosis and Management of
Cervical Spondylotic Myelopathy.Global Spine Jurnal. 2017; 7(6) 572-586.
6. Malanga GA. Cervical Radiculopathy [home page on internet]. 2016.
Available from: https://emedicine.medscape.com/article/94118-overview
7. Duus P. Diagnosis Topic Neurology DUUS. Gottingen and Freiburg:
University of Gottingen. 2012.
8. Eubanks JD. Cervical Radiculopathy: Non-operative management of neck pain
and radicular symptoms. Ohio: Case Western Reserve University School of
Medicine. 2010.