SUBJECTIVE EXAMINATION

A 28 year old women complains of acute non-radicular (somatic) pain in the right neck, right upper arm and radicular (lancinating pain) in the posterolateral upper and lower arm and radial two digits. She also complained of parasthesia in the right posterolateral forearm and radial two digits.

Two days earlier, she had driven past a car accident and stopped to pull a man from his burning car. As she did so she experienced a sudden onset of the symptoms described above and vertigo. The vertigo lasted a few minutes and disappeared and has not since been re-experienced. The other symptoms have remained about the same since the accident.

The patient had no previous history of neck or arm pain or vertigo. X-rays where negative.

OBJECTIVE EXAMINATION

There was no torticollis.

Right rotation, right side flexion and extension where both severely limited with pain and parasthesia reproduced in the right posterolateral arm and radial two digits as previously described by the patient.

There was hypoesthesia to pinprick in the right posterolateral forearm and radial two digits.

Fatigable weakness was felt on right elbow flexion and wrist extension.

Biceps and brachioradialis deep tendon reflexes were reduced when compared with the left arm.

Are there any other tests you would like to do? Can you make a diagnosis and begin management of this patient.

From the distribution of the radicular symptoms (lancinating pain and parasthesia) and the distribution of the motor and sensory paresis it is obviously a C6 radiculopathy. Neither upper limb tension testing (the tissue involvement is obvious) and may even be contraindicated (aggravation of the symptoms or worse by increasing the compression) nor biomechanical testing are required to make the diagnosis.

The cause of the radiculopathy is probably a prolapsed disc. While these are unusual in the cervical spine, they do occur and are more common at this level than higher. The patient's age would argue against any other form of lateral stenosis.

Treatment at this point would probably be traction. However, the patient's vertigo has not been considered. In real life, the physician that she was seeing happened to notice that when the patient turned her head during a conversation at the end of the examination, she developed lateral nystagmus. The physician ordered an angiogram and this demonstrated that the disc that was indeed compressing the nerve root was also compressing the vertebral artery. Traction might well have caused irreparable and severe neurological damage.

Most of us examine the neck from behind and would have missed the nystagmus so what could we have done. From the history, we should have wondered what was the source of the vertigo.

Could it have been from the cervical joints? Yes, but! Cervical vertigo arising from the joints has certainly been demonstrated experimentally and clinically. But not usually as an immediate consequence of trauma and not relenting within a few minutes. Even if we believed that the vertigo was arthrogenic, the more serious causes should have ruled out first.

The vertigo could have been caused by labyrinthine concussion. The effort of pulling the victim from the care could have ruptured the tympanic or vestibular membrane but in this case, the vertigo would have persisted for much longer than a few minutes.

This leaves us with a vertebrobasilar accident. A very rare occurrence and even rarer if not unprecedented in the literature from this type of trauma. However, it is a possibility. At the very least, the patient should have been asked about central neurological symptoms. Has there been any diplopia, visual field defects, other forms of dizziness/nausea, tasted disturbances, hearing difficulties, dysphagia etc. A cranial nerve examination could have been carried out and this might or might not have reproduced signs, although it is probable that occlusion would have to have been present for this. Vertebrobasilar patency testing in the clinic is certainly required in some form. Even if this was only having the patient go through the range of cervical motion while observing for central neurological signs and symptoms and re-testing some of the cranial nerves.

The patient was lucky that the physician happened to observe the nystagmus serendipitously.