A 58-year-old man comes to the office due to worsening right upper extremity weakness over the past 4 weeks. The patient frequently travels for work and has had difficulty carrying heavy bags and getting luggage into or out of the overhead bins. He also has had neck and shoulder pain for the past several months, which he attributes to stress. The patient reports no trauma, and medical history is significant for hypertension. Physical examination shows weakness of shoulder abduction and loss of the biceps reflex on the right side. Pinprick sensation is decreased over the right lateral arm and forearm. Which of the following pathologic processes is most likely underlying this patient's current symptoms?

Question

A 58-year-old man comes to the office due to worsening right upper extremity weakness over the past 4 weeks.  The patient frequently travels for work and has had difficulty carrying heavy bags and getting luggage into or out of the overhead bins.  He also has had neck and shoulder pain for the past several months, which he attributes to stress.  The patient reports no trauma, and medical history is significant for hypertension.  Physical examination shows weakness of shoulder abduction and loss of the biceps reflex on the right side.  Pinprick sensation is decreased over the right lateral arm and forearm.  Which of the following pathologic processes is most likely underlying this patient's current symptoms?

Quizplus · Accepted Answer

11ec160b_35c4_486d_9249_3f6e57c0a717_MD0001_00 This patient's sensory (eg, lateral arm/forearm sensation loss) and motor deficits (eg, impaired shoulder abduction, biceps reflex) are not isolated to the distribution of a single peripheral nerve (eg, median, ulnar), but rather follow the C5 dermatomal and myotomal distribution, indicating cervical radiculopathy. The manifestations of cervical radiculopathies vary depending on the affected nerve root but typically present with neck or arm pain associated with motor and/or sensory deficits. Radiculopathies occur due to compression of spinal nerve roots, which is most commonly due to either: Spinal spondylosis: Aging leads to degeneration of the vertebral bodies, discs, and joints. Disc space decreases, and joint stress results in osteophyte (eg, bone spur) formation, which slowly narrows the neural foramina and leads to a subacute onset of symptoms (as seen in this patient). Vertebral disc herniation: Degeneration of ligamentous fibers can lead to a tear in the intervertebral disc annulus, resulting in herniation of the nucleus pulposus with potential nerve root compression. Disc rupture typically occurs acutely (eg, during weight lifting). (Choice A) Axonal loss in the corticospinal tracts occurs in amyotrophic lateral sclerosis, a neurodegenerative disease that affects both upper and lower motor neurons. Although it can result in weakness and atrophy, it would also result in upper motor neuron signs (eg, hyperreflexia), and sensory disturbances would be atypical. (Choice B) Syringomyelia results from cystic expansion of the central canal in the spinal cord. This can result in upper extremity weakness and sensory deficits, but because it expands from the central portion of the spinal cord, both upper extremities are typically affected, most often in a "cape" distribution. (Choice D) Microinjury and tear of the rotator cuff tendons can result in weakness of shoulder abduction. However, sensory deficits are unexpected. (Choice E) Rupture of the long head of the biceps tendon could result in shoulder pain that is aggravated by repetitive overhead activities; a loss of the biceps reflex may be observed if the rupture is complete. However, it would not cause weakness of shoulder abduction (biceps flexes and supinates the forearm) and sensory deficits would not be present. Educational objective: Cervical radiculopathy typically results in neck and/or arm pain associated with neurologic deficits that follow a dermatomal/myotomal pattern. Osteophytes that form due to degenerative changes in the vertebral joints can progressively narrow the neural foramina leading to nerve root compression.

A 58-Year-Old Man Comes to the Office Due to Worsening