Man-In-The-Barrel. A Case of Cervical Spinal Cord Infarction and Review of the Literature
After bending down to tie her shoes, a healthy 43-year-old woman showed intense cervical pain, irradiating over both shoulders and arms, with numbness and paresis of both arms.\nPhysical examination on admission highlighted evident brachial diparesis, with mainly distal and left impairment. The muscular balance was 5/5 in the right deltoids, 4/5 on the left and 0/5 in the musculature of both hands, associated with left upper arm hyporreflexia with reflexes preserved on the other arm. As for sensitivity, the patient presented tacto-algesic hypoesthesia of both arms and C4-D9 sensory level. The remaining neurological examination was completely anodine.\nA series of additional studies, which enabled us to confirm clinical suspicion of cervical medullary lesion, were performed. Cervical MRI on admission revealed a hyperintense intramedullary lesion in T2 at C3-C7 level (Fig. ), with totally normal cerebral imaging. An arteriography was performed making possible to observe the vertebral, anterior spinal and anterior radiculo-medullary arteries including C7, with no abnormalities found.\nAll laboratory studies, the hypercoagulability test, cerebrospinal fluid (CSF) analysis (negative oligoclonal bands), chest x-rays, ECG and echocardiogram were all normal. Visual, auditory and somatosensory evoked potentials resulted within normal limits.\nGiven the suspicion of cervical medullary infarct we established treatment with acetyl-salicyclic acid (ASA) and intensive rehabilitation. Clinical evolution was favourable showing residual mainly distal brachial diparaesthesia, with amyotrophy and flexor tendency of the fingers on both hands, abolished left tricipital reflex and mild bibrachial tacto-algesic hypoesthesia. Cervical MRI performed after one month revealed myelomalacia and cavity formation at C3-C7.