Presented by:  Dr. Robert Brownstone, Halifax

Age:  46

Sex:  Female

History:

• 1988: C2-C7 laminectomy for resection of ependymoma.

• Patient felt spasticity developed . Neurosurgeon at 4 months post-op noted a flexion deformity in the right arm, able to extend and flex elbow, wrist and fingers and the hand intrinsics were working. 

• spasticity progressed slowly

• pain is spasmodic, particularly in rt axilla, chest wall, and shoulder, less so in the upper arm and hand, even less in forearm and elbow

          -       alleviated: local cold packs, hot packs on back
          -       aggravated: nothing identified
          -       Meds: flexeril, lorazepam, valium. Previously tried many.
          -       Baclofen in past  of no benefit, and then developed allergy

•   1993: ?tumour recurrence, repeat laminectomy for exploration, no tumor. No evidence of recurrence since

Examination:

• No motor C5  T1 Rt (Lt side normal)

• Sensation: L good, R diminished in C4, moreso in C5, absent C6  T1 and down lateral aspect of chest wall. Leg sensation normal

• Gait is good, but unable tandem, toe walking  mild weakness R

• DTRs symmetric, R plantar upgoing

• Initial improvement with neurontin (even in spasticity) but then adverse effects
  Currently trying tizanidine. So far, no improvement.

MRI: 

Questions:

1. What next?