But I Kept The Rubber Side Down

HISTORY: Patient is a 35 yo female cyclist who presents with severe neck pain, radiating into left upper posterior chest, and down the left arm that has been ongoing now for several weeks. She states this pain developed and has been progressive after competing in a mountain bike race. She had an unintentional jump where she landed with her neck hyperextended and upper body/handlebars rotated to the right. She complains of weakness in the left arm and severe pain made worse by sitting, and with any activity involving the use of the left upper extremity. PHYSICAL EXAMINATION: Vital signs: T37.3 BP125/76 P55 R12 O2 Sat 98% General: Well nourished, BMI 19. Cardiac: Symmetric distal pulses. Integumentary: No rashes or discoloration of the left upper extremity. MSK: Shoulder girdle atrophy R: neg L: neg Shoulder Impingement Test R: neg L: neg Scapular Winging R: neg L: neg Spurling’s R: neg L: pos Shoulder Abduction Test R: neg L: pos R: neg L: pos Hoffman’s R: neg L: neg Shoulder flexion R: 5 L: 5 Shoulder abduction R: 5 L: 5 Shoulder Ext Rotation R: 5 L: 5 Elbow Flexion R: 5 L: 5 Elbow Extension R: 5 L: 3 Wrist Extension R: 5 L: 3 Finger Ext R: 5 L: 3 Forearm Pronation R: 5 L: 3 Grip strength R: 5 L: 3 DIFFERENTIAL DIAGNOSIS: Brachial Plexis Injury, Cervical Disc Herniation, Radial Nerve Entrapment, Complex Regional Pain Syndrome TESTS AND RESULTS: MRI Cervical Spine revealed disc protrusions producing stenosis at C5-6, C6-C7, edema of posterior elements at T2-T3 with concern for fracture of T3 Lamina. Imaging obtained through the brachial plexus did not reveal any obvious abnormalities. EMG revealed reduced recruitment(75%) of the triceps only on the left. FINAL/WORKING DIAGNOSIS: C6-C7 Disc Herniation with concurrent neuropraxia. TREATMENT/OUTCOME: Patient underwent trial of oral steroids, then an epidural over the period of one month without relief in symptoms. Cervical disc replacement was performed by neurosurgery, identifying a small disc herniation into the C6-C7 foramen with also significant nerve inflammation. After cervical disc replacement, patient underwent several months of physical therapy. She continued to have weakness of the left tricep along with parenthesias in the left hand at six month follow-up, but resolved almost completely at one year. Athlete returned to full activity at 6 months, and competed again the next season.