| April/May 2008: Middle Aged Man with Cervical Mass |
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HPI: A 65-year-old man woke up in bed 3 weeks ago having noticed bruises on his arms and was concerned that he might have hit himself against the bedpost although he does not recall exactly what happened. He did not have any neck pain at that time. About 5 days later he noticed significant neck pain associated with bilateral arm pain extending down to the level of his wrists but not into his hands. He denies any paresthesias but says that he did have them in the past which would get better with narcotics. He had a CT and MRI of his cervical spine completed and is transferred to your institution for further evaluation because of the findings (see below).
ROS: Denies any recent fevers, chills, weight loss, or travel outside the country.
FH: Mom has breast cancer.
PMH:
1. Atrial fibrillation.
2. Iliac aneurysm.
3. Aortic aneurysm.
Past Surgical History:
1. Cardiac ablations x 3.
2. Cardioversion.
3. Iliac aneurysm surgery.
4. Lumbar diskectomy and fusion.
Medications:
1. Aspirin 81 mg daily.
2. Lasix 10 mg daily.
3. Metoprolol XL 25 mg daily.
4. Coumadin 5 mg daily.
5. Diltiazem 15 mg TID.
6. Gabapentin 300 mg qhs.
7. Vicodin 1-2 tablets PRN.
Social Hx: No tobacco or alcohol use. Retired salesman.
Neurological Examination:
Afebrile. Vital signs stable. He is alert and oriented X 3.
Cranial nerves II-XII are intact.
C-collar in place; no focal tenderness of the neck.
4/5 strength in left hand grasp. Remainder of strength exam is full throughout all muscles groups in the upper limbs and bilateral lower limbs.
Normal sensation throughout upper and lower limbs bilaterally.
Reflexes 2+ throughout.
(-) Babinski/Hoffman sign.
He ambulates with slight stagger secondary to low back pain (chronic and unchanged).
Laboratory Studies:
WBC 4.3, PLT 201, ESR 33, CRP 0, INR 1.9, Ca 9.1
MRI C Spine (from outside facility).
Sagittal T2 without contrast.
Sagittal T1 with contrast.
CT C spine without contrast.
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| 1. What is your most likely diagnosis? |
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| 2. What is the next step in your management? |
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| CT is completed of the chest, abdomen and pelvis and shows slightly enlarged retroperitoneal lymph nodes, none of which are of a size as to suggest malignancy. |
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| 3. What is your next step in his management? |
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| 4. What would be your surgical plan for this patient? |
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3. Please add any suggestions or comments regarding this case:
n/a
cyberknife
gout
He needs an MRI of the brain to evaluate for a cause for the bruises. He may have had a seizure.
make sure that the patient is off of coumadine and cardiaology to help with AFIB management since this patient will be off of coumadine at least for 4-6 weeks.
Case of TB cervical spine with paraspinal abscess.
Possibility of conservative management with ATT is biopsy of tissue is positive for AFB and culture also is positive for AFB, otherwise surgical debridement and fusion.
potts diesease
The patient is taken to the OR and undergoes a C5 and C6 corpectomy with reconstruction using a fibular allograft and anterior cervical plate. His neck pain improves and he is discharged home after 3 days.
Intra-operative specimens are taken.
Pathology reveals: chronic inflammation and granulation tissue; focal osteoclastic resorption, foci of chronic inflammation including macrophages and PMN; no eosinophils seen; CD1a immunostain negative on decalcified tissue.
Microbiology: negative for any organisms.
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