Page 90 - JSOM Fall 2022

Walking Quadriplegic

Cervical Myelopathy in an Ambulating Combat Support Soldier

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Dmitriy A. Treyster, MD, PA-C *; Rebekah Riordan, MD ; Eryn N. Rotello, PA-C ;
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James Falcon, MD, FAAEM ; Grigory Charny, MD, MS, FAAEM 5
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ABSTRACT
We discuss a case of a 27­year­old male Soldier who presented DCS usually requires routine, noninvasive intervention, such
with acute to subacute vague radicular complaints, which were as activity modification and physical therapy. The minority of
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atypical for and out of proportion to the imaging findings. these cases represent DCM, which requires prompt examina­
Imaging demonstrated compressive cervical myelopathy at the tion and surgical evaluation. Unlike DCS, DCM can lead to
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levels of C3/C4 and C4/C5. Paradoxically, the patient’s history spinal cord ischemia and irreversible damage, if not corrected.
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revealed a remote nerve root compression, not cord compres­ This can result in paraplegia, paralysis, and loss of diaphrag­
sion, at the same levels. Identification and prompt surgical matic innervation. Management of DCM is dictated by de­
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management led to the reversal of significant neurologic defi­ gree of disability, risk of progression to devastating neurologic
cits that were present preoperatively. This case highlights the loss, and overall operative risk. No management guidelines ex­
difficulty of identifying this rare condition among a plethora ist for management of DCM in the military population. The
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of otherwise benign and common cervical spondyloses seen in 2017 Clinical Practice Guideline (CPG), based on the AOSpine
the Special Operations population. This study aims to bring study, provides recommendations for grading the severity of
to light the subtle history and physical characteristics that can DCM and guidelines for intervention based on the severity. At
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assist Special Operations healthcare providers in making an the core of the rating lies the modified Japanese Orthopaedic
otherwise elusive diagnosis. Last, it highlights a utility to doc­ Association (mJOA) scoring system, which grades myelopathy
umenting baseline spinal exam findings for the force to better based on functional impairment and classifies it as mild, mod­
identify subtle injuries. erate or severe. However both the CPG and the mJOA rely on
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the general population epidemiology of DCM, which tends to
Keywords: cervical spinal myelopathy; degenerative myelopa- be older and have a more insidious course of disease progres­
thy; cervical spondylosis; military personnel; neurosurgery sion than the highly­active, younger military population.
This case represents the youngest instance of nontraumatic
degenerative cervical myelopathy leading to cord compres­
Introduction
sion in an otherwise healthy patient and the first documented
Degenerative cervical myelopathy (DCM) lies on the se­ case with a cervical cord compression as high as C3­C4 that
vere side of the spectrum of degenerative cervical spondylo­ presented with focal symptoms and no gait abnormalities. A
sis (DCS). As the most common cause of cervical radicular thorough literature review found a 31­year­old Soldier with
disease in the world, DCS results from gradual biochemical cord compression at C6/C7 who presented with bilateral
and biomechanical tissue erosion, leading to spinal canal upper extremity weakness, radicular pain, and a decrease in
narrowing and cord compression. DCM manifests more of­ hand dexterity with hyperreflexia and positive Hoffman signs
ten in men, in the 5th to 6th decade of life. However, special bilaterally. All other documented cases presented with more
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populations, such as military Servicemembers, do not follow severe clinical features, such as gait disturbances (most com­
this demographic pattern. In this population, the incidence of mon), sphincter or bladder dysfunction, and spastic quadripa­
cervical radiculopathy, a manifestation of DCS, increases in resis or quadriplegia. This included a review of 71 patients
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the third decade, and females have a higher relative risk than diagnosed with cervical myelopathy. Additionally, with the
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men. Rank seniority, which correlates to length of military exception of the 31­year­old Soldier noted here, the average
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service, is also a significant risk factor. Other risk factors for age of the other cases discovered was 55.8 years and many
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DCS include participation in sports, lifting, and tobacco use. had other comorbid conditions, such as hypertension, chronic
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Arguably the military cohort tends to be involved in all of the kidney disease, diabetes mellitus, prior cardiovascular event,
aforementioned at­risk behaviors. and history of smoking. 7
*Correspondence to dmitriy.a.treyster.mil@mail.mil
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1 Dr Dmitriy A. Treyster, Dr Rebekah Riordan, and LTC Grigory Charny are physicians affiliated with the F. Edward Hébert School of Med­
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icine, Uniformed Services University, Uniformed Services University, Bethesda, MD. Eryn N. Rotello is a physician assistant affiliated with the
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Troop Medical Clinic, Joint Base Elmendorf­Richardson Hospital, Elmendorf AFB, AK. Dr James Falcon is a USASOC surgeon affiliated with
Clark Health Clinic, Fort Bragg, NC.
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