Attending Physician Memorial Healthcare System Hollywood, Florida, United States
Case Diagnosis: Cervical Myelopathy with Myelomalacia
Case Description: An 80-year-old female presented to the hospital for 2-week history of progressive diffuse morbilliform rash following medication change from Vimpat to Lamictal. Neurology consultant noted upper extremity action tremors which patient noted to be chronic, but acutely worsening and previously attributed to anti-epileptic medications. Physiatry further elicited history of 4-month progressive functional decline from independent to household ambulation with a rolling walker and multiple recent falls. Her examination was notable for unilateral Hoffman’s sign, bilateral ankle sustained clonus, bilateral Babinski sign, broad-based gait, and upper extremity tremors. MRI of the cervical spine identified severe C5/6 central canal stenosis with myelopathy and myelomalacia necessitating C5-C7 laminectomy with C3-T1 Fusion. She was transferred to acute inpatient rehabilitation where she progressed from minimal/moderate assist to modified independent. She notably had resolution in her ankle clonus and Babinski, and improvement in, but not resolution of, her upper extremity tremor.
Discussions: Degenerative cervical myelopathy (DCM) is the leading cause of non-traumatic spinal cord injury which is increasing both in prevalence and economic burden. Several studies have demonstrated delays in diagnosis of DCM are typically 1-2 years, and such delays are associated with increasing disability. Insidious, nonspecific symptomatology, distracting comorbidity, as well as incomplete neurologic examination, history, and/or clinical correlation by practitioners contribute to delays in diagnosis. While it is rare, several cases of “tremor” have been identified as presenting symptoms of cervical myelopathy and may be considered action induced clonus. Like our patient, each of these patients with tremor had additional localizing signs which lead to the correct diagnosis and appropriate treatment.
Conclusions: Given trends and outcomes of delayed diagnosis, clinicians should consider a diagnosis of DCM in elderly patients presenting with vague neurologic complaints and a thorough history and physical remain essential for early detection to avoid sequelae.