WhiteCoat

What’s the Diagnosis #10

A 26 year old female comes in complaining of chronic neck pain for the past 6-8 months. She was seen in the emergency department 4-5 months ago for the same pain and was diagnosed with a neck strain. Since that time, she has had intermittent pain.
She states that the pain is worse when she tilts her head forward or backward and also worse when she coughs.
There is no history of trauma. She has had no fevers or difficulty swallowing. Her vital signs are normal. Her teeth are in good shape with no signs of abscess. Oropharynx is also normal. No meningeal signs are present. She can move her head about fairly easily, but does notice some pain when flexing her head forward. Neurological examination is normal.
She came to the emergency department this time because when she woke up, the pain was worse and she had tingling down her back and into her fingertips when she was bending over to tie her shoes.
Xrays of her cervical spine are below (the AP view was unremarkable).
What is the abnormality on the x-rays? What is the name of the clinical sign that she was demonstrating? Given these two pieces of information, what was her diagnosis?

I’ll post the answers under the x-rays in a couple of days.

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Final Answer:

The patient was indeed exhibiting Lhermitte’s Sign. More common in multiple sclerosis, it can also be caused by other etiologies, including trauma. The presence of this sign and her pain with coughing were what prompted me to order a c-spine x-ray.

Scanman hit the x-ray results right on the nose. Atlantoaxial instability with posterior fusion of C2 and C3. The predental space (between the posterior arch of the atlas and the anterior surface of the dens) should be no more than 3mm. See more about interpreting C-spine x-rays in this AAFP article. In this patient, the predental space was 7 mm. The instability and the patient’s symptoms resulted in a sphinchter tightening moment while we scurried around to find a cervical collar.

Final diagnosis from our ED was shown on CT scan below – odontoid fracture. Probably subacute, but a fracture nonetheless. This occurred in the rural ED where I moonlight, so she was shipped to a tertiary care center.

By the way – I remember from my trauma training that coughing exacerbates the pain of a c-spine fracture, but was unable to find a name to go along with this sign. Anyone know of it? This is the third time I have caught an occult c-spine fracture because the patient complained of pain in the neck with coughing.

 

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19 Responses to “What’s the Diagnosis #10”

  1. Dr. Tim Marnie says:

    Alantoaxial instability.

  2. VA Hopeful says:

    Odontoid fracture allowing C1 to displace anteriorly?

  3. erfltdoc says:

    What was the mechanism for her hangman’s fx?

  4. erfltdoc says:

    Oh, and I think it’s Lhermitte’s sign.

  5. ms-III says:

    possible cervical spondylolysis with a ” scotty dog” sign?

  6. alex21in says:

    Atlanto-axial instability
    Lhermitte’s sign

  7. igloodoc says:

    My guess is an atlanto-axial instability/subluxation and the sign would be the “cock-robin” sign. Does she have Down’s?

    The treatment before the AMA-Obamacare alliance would be surgery. In this post AMA-Obamacare era, the treatment would be a pill.

  8. ERP says:

    Atlanto-axial instability
    L’hermitte’s sign
    Although I am sure despite “Obama Care”, Igloo Doc, surgery would still be indicated and paid for since she is symptomatic with the Lhermitte’s sign.
    If it was discovered incidentally and their were no symptoms, the treatment IS a pill – although I bet there are a boat load of surgeons out there that would salivate at the 100,000+ bill they can charge out of network…

    • igloodoc says:

      oops I stand corrected…Lhermitte’s sign. Cock robin is the way they hold their head, not the pain described. Don’t know if there would be all of those out of network surgeons lining up for the surgery if the health plan were medicaid, though. The surgeons would be too busy chopping off diabetic feet and such.

  9. Vijay says:

    Atlanto-axial subluxation. Posterior fusion of C2 & C3.
    PS. I’ll leave the discussion of clinical findings to the non-rads! ;o)

  10. michael says:

    I’m guessing Arnold-chiari malformation.

  11. michael says:

    Definite Lhermitte’s sign. Arnold-Chiari malformation?

  12. [...] This post was mentioned on Twitter by Vijay , rlbates. rlbates said: Calling on @scanman From WhiteCoat's Call Room: What’s the Diagnosis #10 http://bit.ly/cE8Ova [...]

  13. hashmd says:

    The condition is atlanto-axial subluxation. The diagnosis is Rheumatoid Arthritis causing destruction of the ligaments holding the odontoid in place.

  14. Sarah G says:

    Stupid thought: any chance a bad chiropractic adjustment was involved?

    • Cliff says:

      haha, that would be pretty bad, if not impossible to produce that with a chiro adjustment (no reported cases in the literature)

  15. Webhill says:

    I’d call it Wobbler’s syndrome. She’s not a Doberman is she? :)

  16. Chirodoc says:

    In this case, there is atlanto-axial instability due to compromise of the transverse ligament of the atlas, either due to trauma or a disease process (there are a number of conditions that can cause this compromise). The appearance at the C2-3 facet joints appears to be a fusion, but is likely a pseudo-fusion. On lateral cervical spine radiographs, this may be a normal anatomic variant. A pseudo-fusion is due to the oblique orientation of these facet joints relative to the X-ray beam and is usually unaffected by patient position.

  17. Cliff says:

    I don’t believe there is C2/3 fusion here – this is a common error in interpreting x-rays. Chirodoc is correct.

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