Neck Pain in a Performing Arts Student

Abstract

HISTORY: 24-year old female operatic student at a performing arts school with history of C5-6 left paracentral disc protrusion presented with worsening left-sided neck pain that began 1 day after a low impact motor vehicle accident (MVA). At the visit she denied any upper extremity tingling, numbness or weakness. She denied headaches, head injury or symptoms of concussion. PHYSICAL EXAM: She had full active range of motion of her cervical spine but some left-sided neck discomfort with right lateral flexion and rightward rotation. Her C-spine was tender in the midline at C7. Spurling’s was negative and upper and lower extremity neurological exams were normal. DIFFERENTIAL DIAGNOSIS: 1. Cervical disk pathology (worsened from previous) 2. Cervical muscle strain/soft tissue sprain 3. Bony injury TESTS AND RESULTS: Cervical spine AP, lateral flexion and extension views: Normal MRI Cervical spine 1. Concentric T1 hyperintense signal involving the left vertebral artery at the C5-6 level suspicious for focal dissection with intramural hematoma 2. Small left paracentral disc protrusion, largely unchanged from prior study MRA: Vertebral artery dissection at the V2 level with intramural hematoma and <33% artery narrowing MRI Brain obtained to evaluate for occult stroke: normal FINAL WORKING DIAGNOSIS: Traumatic left vertebral artery dissection TREATMENT AND OUTCOME: 1. Started on oral aspirin, discharged to outpatient follow up 2. At follow up 1 week later, MRA showed worsening vertebral artery dissection with concern for complete occlusion 3. CTA ordered to further assess artery lumen, confirmed that artery was not completely occluded 4. Admitted and started on IV anticoagulation; discharged on rivaroxaban 5. Currently restricted from dance and any vigorous activities or exercise, will reassess activity level at 3mo follow up with Neurology