A 67-year-old man seeks medical attention because of unsteadiness and near-falls over the last several weeks. He has noticed some numbness in his hand and urinary urgency more frequently than what he usually experiences. He also describes many months of neck pain, shoulder discomfort, and lower back pain. There is no history of neck or back trauma. He has had no fever, chills, or weight loss. He denies any headaches, vertigo, vision loss, or difficulty swallowing.
He rides an indoor exercise bicycle for 45 minutes three times a week and goes for 3-4 hour outdoor rides on his bicycle both weekend days. He had a normal colonoscopy within the past five years. He takes no medications other than a daily multivitamin. He does not smoke or drink alcohol.
His temperature is 37.0 C (98.6 F), blood pressure is 155/84 mm Hg, pulse is 85/min, and respirations are 14/min. There is 4/5 muscle strength in his bilateral lower extremities with 3+ reflexes. Upper extremity examination is normal except for mildly decreased sensations in both hands. No muscle atrophy or fasciculations are present. His Mini Mental Status Exam score is 29/30.
Laboratory data reveal the following:

EKG shows sinus rhythm with left ventricular hypertrophy. Chest X-ray shows mild cardiomegaly but clear lung fields. A cervical spine series demonstrates degenerative changes in the C5, 6, and 7 areas.
Which of the following is the most likely diagnosis?

Question

A 67-year-old man seeks medical attention because of unsteadiness and near-falls over the last several weeks.  He has noticed some numbness in his hand and urinary urgency more frequently than what he usually experiences.  He also describes many months of neck pain, shoulder discomfort, and lower back pain.  There is no history of neck or back trauma.  He has had no fever, chills, or weight loss.  He denies any headaches, vertigo, vision loss, or difficulty swallowing.
He rides an indoor exercise bicycle for 45 minutes three times a week and goes for 3-4 hour outdoor rides on his bicycle both weekend days.  He had a normal colonoscopy within the past five years.  He takes no medications other than a daily multivitamin.  He does not smoke or drink alcohol.
His temperature is 37.0 C (98.6 F), blood pressure is 155/84 mm Hg, pulse is 85/min, and respirations are 14/min.  There is 4/5 muscle strength in his bilateral lower extremities with 3+ reflexes.  Upper extremity examination is normal except for mildly decreased sensations in both hands.  No muscle atrophy or fasciculations are present.  His Mini Mental Status Exam score is 29/30.
Laboratory data reveal the following:

EKG shows sinus rhythm with left ventricular hypertrophy.  Chest X-ray shows mild cardiomegaly but clear lung fields.  A cervical spine series demonstrates degenerative changes in the C5, 6, and 7 areas.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_9872_cb0b_853d_17ef14b48824_MD0002_00 Cervical spondylosis is a progressive degenerative process of the cervical vertebral bodies and discs (most common in adults age > 55) that can result in disc herniation, osteophyte formation, and hypertrophy of the posterior longitudinal ligament and ligament flava. These processes can lead to cervical spinal canal stenosis, mechanical spinal cord compression (in about 5-10% of individuals), and spinal cord ischemia (due to compression of the arterial and venous supplies of the cord). Flexion and extension of the neck can exacerbate cord compression while extension of the neck (which may occur when this patient bicycles) reduces the diameter of the spinal canal and causes inward buckling of the ligamentum flavum. Both MRI and CT can be used to diagnose cervical cord compression. MRI is preferred since it provides better intramedullary detail of the spinal cord while CT gives better images of bone and calcified tissues. There should be careful clinical and anatomic correlation since there is a high frequency of MRI abnormalities of the cervical spine in asymptomatic older individuals. Conservative treatment with cervical immobilization is indicated for mild myelopathy while surgical decompression is reserved for patients who fail conservative measures, severe myelopathy or progressing deficits, or acute deterioration with cord compression. (Choice A) Both amyotrophic lateral sclerosis (ALS) and cervical cord compression can occur in older individuals and produce a combination of upper and lower motor neuron findings. ALS generally has lower motor neuron deficits and fasciculations in the lower extremities and cranial muscles, while cervical cord compression has deficits isolated to the affected dermatome. ALS usually does not cause sensory deficits while cervical cord compression may have subtle or absent sensory deficits. This patient does exhibit some sensory deficits, which would make ALS unlikely. An electromyogram, which usually documents denervation in ALS, may be helpful to distinguish between the two disorders. (Choice C) Chronic or subacute Guillain Barré syndrome can present as progressive upper and lower extremity weakness, but reflexes are lost or diminished in contrast to the hyperreflexia seen in this patient. (Choice D) The combination of gait impairment and urinary symptoms may suggest normal pressure hydrocephalus; however, this patient does not have cognitive dysfunction which is usually seen with normal pressure hydrocephalus. (Choice E) Transverse myelitis usually occurs in a younger population and presents with a segmental cord syndrome, which is not present in this case. Spinal cord MRI and cerebral spinal fluid analysis are required for diagnosis of transverse myelitis. Educational objective: Cervical spondylotic myelopathy is a relatively common and potentially treatable cause of progressive disability in older adults. This condition often presents with upper motor neuron signs in the lower extremities and lower motor neuron signs in the upper extremities. MRI is the diagnostic study of choice. __________ References: Cervical spondylotic myelopathy: make the diagnosis, then refer for surgery. (http://www.ncbi.nlm.nih.gov/pubmed/14621236) Cervical spondylotic myelopathy: patterns of neurologic deficit and recovery after anterior cervical decompression. (http://www.ncbi.nlm.nih.gov/pubmed/10201301)

A 67-Year-Old Man Seeks Medical Attention Because of Unsteadiness and Near-Falls