The Importance of Personally Reviewing Imaging for Clinical Correlation

Abstract

A 64-yr-old man with a history of previous motor vehicle collision with chronic back pain presented as a referral to an outpatient spine clinic with a 3-yr history of bilateral lower limb weakness and numbness that progressed to severe bilateral foot drop. He had been seen by another practitioner from a different hospital 2 yrs prior who performed an electromyography that was interpreted as possible primary lateral sclerosis. His clinical picture was difficult to interpret as it did not fit any of the disease patterns, such as a motor neuron disease, suggested by previous electromyography. Repeated magnetic resonance imaging revealed multifactorial canal stenosis at L3-L4 and L4-L5 with foraminal stenosis. The ordering physician reviewed the magnetic resonance imaging of lumbar spine and noticed possible spinal canal stenosis in the lower thoracic region, not noted by the radiologist, and ordered a magnetic resonance imaging of thoracic spine for further evaluation. Overall, this is an interesting case of a patient who had prolonged weakness and numbness in his lower limbs that, although he underwent extensive workup, was misdiagnosed. It is important to realize that thoracolumbar disc herniations can cause mixed upper motor neuron and lower motor neuron signs. This case emphasizes the importance of reviewing the patient’s imaging personally and correlating the imaging to the clinic presentation.