My Arm Hurts.

1. Umar Khan , MD SEACSM 2/5/2011 My Arm Hurts.

2. C/C and HPI • “My arm keeps getting hurt” • 18 yo male football player with recurrent history of arm pain. Has been having symptoms off and on since 2007. Symptoms were bilateral on occasion, but usually down one arm or the other. Three years ago, playing football while tackling, contact sent symptoms of pain, numbness and weakness down both arms. Patient doesn’t remember if he returned to play symptom free, however that football season, “every impact” he had would reproduce symptoms (down both arms or either arm). Parents noted continued weakness in his upper extremities two months after that football season. He didn’t play in 2008, and in 6/2009 while cutting the grass, patient lifted up his lawnmower and had numbness and tingling down his left arm.

3. HPI cont’d • In 2009, he played football without any symptoms, was evaluated for the first time in 2009 before playing. • 9/2010, had another episode, affecting his right arm. He initially stated this was his 1st episode of the year, however later on repeat f/u evaluation, he admitted that he would have symptoms a few times per week, but “they weren’t bad enough to tell anybody about it”.

4. Unremarkable PMHx, Sx, Fam Hx, Social Hx. No meds or allergies.

5. P.E. • Gen: WN, WD NAD • 5’9” 160 lbs • Neck Exam: no ttp along c-spine or paravertebral muscles, he did have ttp on his right trapezius muscle. Neck had FROM and full strength in all directions without symptoms. Spurling’s test was positive reproducing symptoms on his right and causing right trapezius pain. • Neuro exam: CN II-XII intact, DTRs 1+ and symmetric in his upper and lower extremities, Motor strength was 5/5 and symmetric in all 4 extremities both proximal and distal. • Negative Hoffman’s and inverted BR reflex.

6. D/D • Recurrent Stingers • Cervical Canal Stenosis • Burning hand syndrome • Malingering • Acute Brachial Neuropathy • Tumor • Cervical Cord Neuropraxia

7. 2009

8. 2009

9. 2010

10. IMAGING • Standard Cervical Spine X-Rays, shows no pathology except for loss of lordosis. • MRI on 8/10/09: No disk bulging or protrusion present, normal vertebral body heights. No edema in the bones or spinal cord. No evidence of foraminal narrowing or spinal cord stenosis. • MRI on 10/16/10: Normal cervical spine, C3-C4 level small bulging disc on the right, also some minimal disc bulging at C4-C5. No evidence of spinal stenosis. Loss of lordosis in the cervical spine. SAC 5.5mm

11. Sagital-diameter spinal-cord, spinal-canal, and vertebral-body diameter measurments. x = sagittal spinal-cord diameter, y = sagittal spinal-canal diameter, z = sagittal vertebral-body diameter.

12. Final working diagnosis • Recurrent brachial plexopathy • Spear tackler’s spine.

13. Rx • Relative Rest, Avoid Contact sports for now • NSAIDS if currently symptomatic • Rehab/PT

14. Outcome • F/U in 3 months. With repeat films to see if there is return of lordosis of the cervical spine.

15. Return To Activity • Once he has lordosis of his cervical spine and is asymptomatic, and has a normal strength and full range of motion. Will give him a trial of activity.

16. No Contraindications to Return to Play ** • Single-level Klippel-Feil deformity/congenital fusion below C2 • Spina bifida occulta • Resolved stinger or brachial plexus neurapraxia (2 or less) • Healed herniated disc • Healed subaxial cervical spine fracture (C3-C7) • Healed facet fracture • Healed lamina fracture • Healed spinous process fracture (clay shoveler's fracture) • Healed one-level anterior cervical fusion • Healed single or multiple level posterior cervical foraminotomy

17. Relative Contraindications to Return to Play ** • Resolved transient quadriplegia (1 episode) • Resolved stinger or brachial plexus neurapraxia (3 or more) • Non-healed/non-resolved asymptomatic herniated disc or severe foraminal stenosis • Healed C1 fracture • Healed C2 or Odontoid fracture • Any healed subaxial spine fracture with minimal or mild residual displacement, deformity, or decreased range-of-motion • Healed two-level anterior cervical fusion • Healed one-level posterior cervical fusion

18. Absolute Contraindications to Return to Play or Participation ** • Clinical or radiographic evidence of rheumatoid arthritis, anklosing spondylitis, or diffuse idiopathic skeletal hyperostosis • Arnold-Chiari malformation • Os odontoidium or congential odontoid agenesis/hypoplasia • Klippel-Feil deformity/congenital fusion or anomaly involving C1 and/or C2 • Multiple-level Klippel-Feil deformity/congenital fusion below C2 • C1-C2 hypermobility or instability (ADI > 4 mm) • Spear tacklers spine deformity • Transient quadriplegia (2 or more episodes) • Non-healed/non-resolved symptomatic herniated disc or severe foraminal stenosis • Cervical myelopathy • MRI evidence of spinal cord contusion, edema, or abnormality • Any healed cervical spine fracture/dislocation (lateral mass fracture with subluxation/dislocation) • Any healed cervical spine fracture or injury with residual instability > 3.5 mm/11° • Any healed subaxial spine fracture with residual displacement, deformity, or decreased range-of-motion • C1-C2 fusion • Three-level (or more) anterior cervical fusion • Two-level (or more) posterior cervical fusion • Cervical laminectomy or laminaplasty