An unusual cause of progressive quadriparesis
A 55-year-old lady presented with complaints of neck pain for past 1 year and progressive quadriparesis of 2 months duration and was bed ridden at presentation. There was no history suggestive of lower cranial palsies or sphincteric abnormalities. She underwent surgery for multinodular goiter 15 years ago. Clinically, her vital signs were stable and general physical examination was non-contributory. Neurologically she was conscious, alert with involvement of lower cranial nerves (absent gag reflex and wasting of sternocleidomastoid and trapezius). However, there was no facial sensory loss or Horner's syndrome. Motor examination revealed spasticity of all four limbs. Power was grade 2/5 power proximally and 1/5 distally in left upper limb; whereas, it was grade 0/5 in all other limbs and there was weakness of neck and trunk muscles. Graded loss of all modalities of sensation was noted from C3 dermatome downward without sacral sparing. Examination of neck showed a pulsatile swelling in the right retromastoid region, well-healed scar of previous surgery and solitary nodule in the right lobe of the thyroid. Investigations revealed normal hemogram, biochemistry, normal thyroid function with 2.5 cm × 1 cm nodule in the right lobe of thyroid on ultrasonography. Computed tomography of neck revealed a large tumor destroying C1 and part of C2 vertebrae, occupying craniovertebral junction and encroaching into the cervical canal causing severe compromise [Figure and ]. Through posterolateral approach to the craniovertebral junction, decompression with occipito C3 and C4 vertebrae fusion using Magerl's technique was carried out []. Histopathologically, biopsied tissue showed thyroid follicles filled with colloid within skeletal muscle and connective tissue. There were no papillae giving a diagnosis of metastatic follicular carcinoma of thyroid []. She later underwent completion total thyroidectomy and I131 Radioiodine ablation along with external beam radiotherapy of residual neck mass. Histopathological examination of thyroidectomy specimen also confirmed finding of follicular carcinoma of the thyroid in a solitary nodule. At follow-up after 3 months, her spastic quadriparesis still persisted though the power had improved to 4/5 power proximally and 2/5 power distally in all four limbs.