Cervical Cord Case Studies

DOI: 09/11/2014. This is a 56-year-old female certified nurse assistant who sustained neck, bilateral shoulder blades, and upper as well low back injuries when she fell forward and grabbed unlocked side bed rail. MRI of the cervical spine done dated 12/15/2015 revealed 2 to 3mm bulges at C5 to C6 with bilateral foraminal narrowing at C5 to C6 and mild right foraminal narrowing at C6 to C7. There are 2mm disc bulges contacting the cord at C3 to C4 and C4 to C5. The cervical spinal cord demonstrates normal signal intensity and caliber. The vertebral bodies are normally aligned. There are minimal anterior osteophytes at C3 to C4 and C4 to C5. As per office visit note dated 4/12/16, the patient complains of constant neck pain. The pain radiates
into the bilateral upper extremities, the pain is greater on the right side. There is reduced range of motion. There is bilateral shoulder pain. The pain is described as off and on in terms of frequency. The pain radiates into the left thumb. Examination of the cervical spine demonstrates tenderness to palpation over the midline cervical spine, bilateral paraspinals, bilateral upper trapezius, and bilateral levators. Examination of the left shoulder revealed tenderness to palpation over the anterior, superior, posterior aspect, upper trapezius, levators, and rhomboids. There is positive Neer, Hawkins and Jobe testing. There is pain with flexion, abduction, and external rotation. Examination of the right shoulder also revealed tenderness to palpation over the paraspinals, upper trapezius, levators, and rhomboids. There is positive Neer, Hawkins and Jobe testing. There is pain with flexion, abduction, and external rotation. Diagnoses include cervical spine degenerative disc disease/spondylosis; left shoulder supraspinatus tendinosis and acromioclavicular joint degenerative changes, left hand/thumb pain, left wrist carpal tunnel syndrome, right wrist carpal tunnel syndrome.