CASE
A 34-year-old male presented with complaints of progressive paresthesias in the arms and legs following a grand mal seizure 2 weeks earlier. He felt numbness in his chest and soreness in his abdomen. The patient also had posterior neck pain, vague pain that radiated into the arms, trouble with balance, and weakness in his hands. He denied any trauma, headache, vision changes, bowel or bladder incontinence, tinnitus, or speech difficulty.
The patient's history was significant for a seizure disorder of unknown etiology and depression. His last seizure was about 1½ years ago, and he had been on valproic acid (Depakote) since then. He had smoked cigarettes for the past 15 years, and he drank three alcoholic beverages per week.
On physical examination, the patient appeared to be in no acute distress. His cranial nerves were intact. Strength was measured 5/5 at the deltoid, bicep, and tricep, and he had a 1-2/5 with grip and intrinsic hand muscle testing bilaterally. Lower extremity strength was 4/5 in the iliopsoas and quadriceps and 4+/5 with dorsiflexion and plantar flexion testing bilaterally. Sensation was decreased to light touch in all four extremities and was greatest in the hands. Hoffmann sign was positive bilaterally, and he was hyperreflexive in all four extremities. His gait was wide-based and spastic.
The patient underwent electromyography (EMG), nerve conduction velocity, CT of the head, and MRI of the cervical spine. EMG and CT findings were unremarkable. MRI revealed severe stenosis at C4-5 and C5-6 and kyphosis across the C5 body. Cord changes and edema were present on the MRI from C4 to C6 (Figure 1).
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