Neurosurgical Evaluation

DATE: 3/25/08
Mr. XXX is a 53-year-old, right-handed, white male, referred for a neurosurgical evaluation.
He says that he noticed difficulty performing finger pushups sometime in late January of this year. He also started noticing atrophy of the right hand. He reports weakness in the fourth and fifth fingers of the right hand. He does not describe any significant neck pain or radiating symptoms into the arms.
Two months or so ago he developed tingling and numbness involving the fingers of both hands, especially on the right side. He has been using splints with complete resolution.
He sought the attention of Dr. XXX on February 20. His workup included electrophysiological studies on 3/6/08 revealing bilateral carpal tunnel syndrome, a right ulnar neuropathy and a right C6-7 radiculopathy.
An MRI study of the cervical spine was performed on 3/3/08 for a possible thoracic outlet syndrome. He was found to have a moderately sized disc protrusion at the C3-4 level with large disc protrusions at the C4-5, C5-6 and C6-7 levels. He was advised neurosurgical evaluation.
He reports having difficulty unlocking his, car door with a key, writing his name and using tweezers.
He has had difficulty turning his head because of stiffness of the neck, especially to the left side, for over 20 years. He finds it uncomfortable to lie down on the right side because of shoulder discomfort. He says that he "cracks the neck" frequently.
His past medical history is remarkable for hypertension.
His review of systems includes weight loss and cold hands.
He denies coronary artery disease, asthma, emphysema, incontinence or retention of urine, chronic constipation or diarrhea, unexplained skin rash, diabetes mellitus, thyroid disease, seizures, strokes, anemia, cancer and psychiatric illnesses.
His surgical history includes an abdominoplasty.
He reports having lost over 100 pounds of weight over the past three years necessitating the procedure.
His family history is unremarkable for neurological illnesses.
His current medications include vitamins, fish oil, aspirin and Glucosamine Chondroitin. He apparently has been on anti-hypertensive drugs at one point.
He has no known drug allergies.
He does not smoke cigarettes. He denies alcohol consumption.
On examination his blood pressure is 176/88 in the left arm, sitting position with a pulse of 66/min. He is 5 feet 7 inches tall and weighs 163 pounds.
He is pleasant and does not appear to be in acute distress. He is cooperative.
His memory is intact. His attention span and affect are normal. dysphasia or dysarthria.
His pupils are equal, reacting directly and consensually. Extraocular movements and visual fields are full. He has no nystagmus.
He has no carotid bruits. He has adequate pulses universally.
Cranial nerve functions are intact.
He has no skin rash or joint deformities. There is no peripheral edema, clubbing or cyanosis. He has a circumferential scar over the abdomen and back. He has ecchymosis over the volar aspect of the right forearm.
He walks without a limp. He has no ataxia. Romberg's test is negative.
Movements of his neck are moderately limited in extremes of flexion, extension, lateral flexion and rotation. He has no tenderness posteriorly. There is no paravertebral spasm.
Motor exam shows adequate proximal and distal strength in the left upper and both lower extremities. In the right arm, however, he has a weaker grip and slight weakness in the elbow extensors. He also has weakness in the finger adductors and abductors as well as thumb opposition.
He has atrophy involving the hypothenar eminance as well as the dorsal interossei, very prominent over tile first. He does not appear to have any atrophy in the left hand.
Tinel's sign is questionably positive over the elbows and wrists.
He describes slight hypesthesia in the ulnar nerve distribution of the right forearm and hand.
Deep reflexes are absent in the upper extremities. Knee jerks are elicited symmetrically. Ankle jerks are absent. Plantars are flexor bilaterally.
Posterior colu~~ functions are intact. He has no cerebellar decomposition to movements.
In summary, Mr. XXX describes symptoms of weakness in the right arm associated with atrophy, apparently noted towards the end of January of this year.
I reviewed the MRI study of the cervical spine performed recently. He has significant degenerative disc disease with anterior and posterior osteophytes especially at the C5-6 and C6-7 levels. He has a right disc protrusion/osteophyte at the C4-5 level, a left paracentral disc protrusion/osteophyte at the C5-6 level and a very large disc herniation/osteophyte at the C6-7 level. There are minimal changes at the C7-Tl level. I get the impression that he has cord myelomalacia behind the vertebral body of C7.
I discussed with him the different modalities of treatment. He has multiple pathology accounting for his symptoms.
The atrophy in the right hand could be the result of the C7 radiculopathy or the ulnar neuropathy. Less likely diagnosis would include motor neuron disease.
He is not interested in surgery for his carpal tunnel syndrome at this point in time. He also appears to be more interested in addressing the cervical spine pathology with disease at least three levels.
I discussed with him the indications and possible complications relating to a microsurgical anterior discectomy and fusion at the C4-5, C5-6 and C6-7 levels. He understands the guarded prognosis.
Pending any decision regarding treatment, he is advised against any significant trauma to his neck.
He wants to think about the matter and will let me know about his ultimate decision regarding management, understanding that surgery will not reverse the atrophy in the hand.

Page Theme - Tummy Tuck, Abdominoplasty