Case Diagnosis: Patient is a 34-year-old female with worsening right hip pain with MRI concerning for a herniated spinal cord.
Case Description or Program Description: Patient presented to PM&R clinic with right hip pain concerning for S1 radiculitis. She was treated with physical therapy but was not able to find relief. MRI of the lumbar spine was then performed without evidence of S1 pathology, rather, the images were concerning for T12 syringohydromyelia. MRI with contrast was offered but was differed due to the patient’s desire to avoid contrast while breastfeeding. Subsequently, the patient developed a new onset bilateral lower extremity hyperreflexia. She then underwent an MRI of the cervical and thoracic spine with contrast concerning for T7 anterior spinal cord herniation vs. posterior arachnoid cyst. Patient case was discussed with Neurosurgery, and patient was referred to their clinic.
Setting: Outpatient Physiatry Clinic
Assessment/Results: CT myelogram was ordered to confirm the findings and the patient was referred for neurosurgical evaluation. The differential diagnosis includes spinal cord herniation, posterior arachnoid web, and posterior arachnoid cyst.
Discussion (relevance): This case highlights the importance of continued thorough neurologic and musculoskeletal physical examination in the PM&R clinic.
Conclusions: A thorough neurologic and musculoskeletal physical examination can help to elucidate subtle changes, and prevent progression of potentially devastating injury. New or ongoing patient evaluations should consider both common and alternative causes of pain, including rarer diagnoses.