spinal cord pathology

HISTORY OF PRESENT ILLNESS

John Harvey Hamann is a 60-year-old male with a history of right lacunar infarct in September 2022, hyperlipidemia, depression and anxiety who is referred to Mayo Clinic Health System Neurology for prior stroke and paresthesias.

Mr. Hamann presents alone, but is a fair historian. He notes that in September of 2022 he had a fairly abrupt onset of left-sided facial droop, drooling from the left side of the mouth. He also felt generally unwell, and so he sought emergency medical attention.

Because of his symptoms, he underwent MRI of the brain. This subsequently showed a small right lacunar infarct involving the posterior limb of the internal capsule. He was placed on aspirin as well as high-dose statin therapy, which he has continued to today. He continues to smoke, however.

In terms of residual from that event, really he has not much in the way of symptoms outside of some slight left face asymmetry. Over the last 4-5 months or so he has noted the gradual onset of right side involving initially the leg and then the arm, a patchy numbness and paresthesias. These are essentially there every day and constantly, but they can fluctuate in severity. Now, over the last 3-4 weeks, he has noticed symptoms involving the left side, again involving initially the leg and then the arm. He has not noticed any significant changes in bowel or bladder control or severe urinary urgency. He does declare some mild balance difficulties, although these sound as though they may be more longstanding.

Because of his symptoms, he underwent a repeat MRI of the brain in early October. This showed scattered T2 FLAIR hyperintensities consistent with small-vessel ischemic disease, but no evidence of acute infarct or new significant changes in small-vessel disease. No additional testing has been completed.

REVIEW OF SYSTEMS:
REVIEW OF SYSTEMS

OBJECTIVE
PHYSICAL EXAM
General: Male in his 60s, alert, attentive, no acute distress
Vitals: BP 118/82, HR 61
Neuro: Alert and oriented. Cranial nerves show slight asymmetry of the left nasolabial fold which essentially abates with activation. There is full strength proximally distally in the upper and lower extremities with the exception of some slight left ankle dorsiflexion weakness out grade at -1. Coordination is intact on the left with very minimal dysmetria on the right with finger-nose-finger testing with eyes closed. He does have hyperreflexia most notable at the bilateral patella where there is crossed adductor signs and +2 reflexes bilaterally. In the upper extremities I would grade his reflexes at +2 on the left and +1 on the right negative Hoffmann sign. His plantar responses showed minimal response to slightly extensor response more prevalent on the right. His casual gait is within normal limits.
For details of the neurologic examination, please see the neurologic examination form.

ASSESSMENT / PLAN
#1 Numbness involving right arm and leg and now left arm and leg; query evolving cervical myelopathy
#2 Right internal capsule lacunar infarcts September 2022
#3 Hyperreflexia

I discussed my thoughts with Mr. Hamann. Overall, his clinical history as well as neurologic exam is suggestive of perhaps a spinal cord pathology in the low cervical or upper thoracic spinal cord. His hyperreflexia as well as evolving paresthesias or numbness and balance issues would raise a suspicion for pathology there either in terms of intrinsic cord inflammation, which is relatively less likely, or mechanical compression from herniated disc. He did have an MRI of the cervical spine in 2021 which did show some mild narrowing but nothing prominent.

I discussed with him that given his findings, I would recommend obtaining an MRI of the cervical spine with and without contrast to evaluate for any potential pathology involving the cervical spine, and he is in agreement with that. Additionally, given his medical history, I recommended obtaining a carotid ultrasound, although relatively less likely to show significant pathology. Pending those results, additional testing including potentially EMG could be pursued. Will await those results and communicate those to him when those are available.

He voiced understanding, and he is in agreement with the stepwise plan.

OK, Now what? 🤞🧐🙃