Case Diagnosis: 58-year female with gait abnormality and functional decline 9 months after acute back injury
Case Description: Presented to PCP with acute lumbar back pain from lifting a couch and difficulty walking, without "red flag signs." MRI showed bilateral L5/S1 neural foraminal stenosis so prescribed Medrol, cyclobenzaprine, and referral to physical therapy (PT). Pain resolved after 12 weeks of PT, difficulty with ambulation persisted. Previously walked independently, now required rolling walker for short distances. 8 months later, evaluated at outpatient PM&R with minimal back pain, no radicular symptoms or alarm signs. Notable findings on exam were right greater than left distal LE weakness, hyperreflexic patellars, and unsteady, ataxic gait. MRI of cervical and thoracic spine obtained to investigate myelopathy concerns which revealed large T10/11 right paracentral disc herniation with cord signal change, indicating compressive myelopathy. Urgent spinal cord decompression and T9-T12 fusion were performed by neurosurgery.
Discussion: Persistent myelopathy must be addressed to avoid permanent spinal cord injury. Clinicians often expect myelopathy with extremity weakness, upper motor neuron signs, neuropathic pain, sensory changes, or incontinence. Gait ataxia is particularly revealing. However, thoracic spine is frequently overlooked as potential site of pathology, especially in patients presenting after traumatic events. This case emphasizes importance of further evaluation when patients report resolution of acute back pain without improvement in functional deficits following conservative management. Relying solely on reported pain, typical cord compression symptoms, and initial imaging can lead to a missed diagnosis with life-altering consequences.
Setting: Outpatient rehabilitation
Assessment/Results: Post-operative course was uncomplicated, discharged with home health physical and occupational therapy. Now with improved LE weakness and progressively longer ambulatory distances using front wheel walker, goal of returning to independent ambulation.
Conclusion: Thoracic myelopathy should be considered in patients with persistent gait abnormality and/or decreased balance/coordination in setting of acute back injury, despite absence of traditional signs of cord compression.