Poster 325: Functional Decline in a Tetraplegic Patient Following CT Myelogram in the Evaluation of Discogenic Pain: A Case Report

Abstract

Setting: Spinal cord injury inpatient unit. Patient: A 65-year-old man with incomplete tetraplegia. Case Description: The patient had traumatic injury in 1958, leading to incomplete tetraplegia. Patient had excellent recovery with ambulation without assistive devices and independent in most activities. For the past 10 years he has had lower back and bilateral lower-extremity pain. The pain was not relieved by physical therapy or epidural injections. It was unclear if the patient was suffering from spondylosis or lumbar radiculopathy. As the years continued, progressive weakness occurred in the bilateral lower extremities. The patient was found to have a syrinx 4 years ago and underwent decompression, which unfortunately led to worsening lower extremity weakness and spasticity. The patient was stable until October 2007, when he had a computed tomography (CT) myelogram to rule out discogenic pain. The patient suffered after the procedure from worsening functional status, lower extremity strength, and spasticity. Assessment/Results: The physical examination revealed intact sensation at the C4 level with incomplete sensory injury below this level. Examination also revealed B/L upper and lower extremity weakness. Bilateral lower extremity had 1/5 hip flexors, 3/5 knee extensors, 0/5 ankle dorsiflexors, 1/5 long toe extensors, 2/5 ankle plantar flexors. Upper extremity strength was 4/5 elbow flexors, 4/5 wrist extensors, 1/5 right elbow extensors, 3/5 left elbow extensors, 4/5 right finger flexors, 3/5 left finger flexors, 1/5 right finger abductors, 0/5 left finger abductors. Motor strength was less than had been previously observed prior to CT myelogram. Patient was admitted for full rehabilitation to the inpatient service. Conclusions: The history and physical examination indicate a likely functional decline after administration of a CT myelogram to rule out discogenic back pain. It is imperative that the risks and benefits be weighed significantly with these imaging studies, especially in cases of spinal cord injuries. Even slight decreases in strength and sensation can lead to devastating functional losses. In this situation the cost of the side effects of myelography far outweighed the potential benefits for diagnosing pain.