1st February, 2023
A.A , 70YEARS, MALE,
Clinical impression: Vertebrobasilar Insufficiency from known cervical spondylotic disease to R/O recurrent disc or adjacent disc disease.
Management: Conservative management
The above-named patient is a known but controlled hypertensive and presented today with complain of recent (2months) exacerbation of neck pains radiating to both shoulders but worse on the left side. No particular aggravating factors but relieved by rest and neck collar.
He has light sensation of weakness on the left upper limb. Some impaired competence with gait and balance. He has significant past history of anterior cervical decompression in December 2019 at NOH (Dala Kano) due to similar complains & profound weakness on left upper limb.
These symptoms improved tremendously after the surgery and enjoyed his life until recent.
He has also suffered recurrent attacks of dizziness, vertigo and in one occasion was reported as hypotension triggering his very initial symptoms (since 2017). These symptoms have been persistence and bring concerns.
Neurological examination: He is conscious, oriented in time, place and person. Slight gait imbalance. Full power, tone is intact and reflexes are normal.
MRI cervical scan pre op shows mild post op lateral discretion at C4. No post op scans available for review.
FBC: WBC-4.37, PCV- 38.16
EUCR: Na- 139.8, K- 3.93, Urea – 21.86, Cl – 104, HCO3 – 21.31, Cr- 0.73, Cal-2.33
FLP: HDL- 136.2
MRI Cervical Spine shows perfect healing at C3/C4 which was previously had ACDF cervical lordosis well preserved. Cord architecture well defined with surrounding subrachnoid space.
CT Angiogram does not suggest any major encroachment on the vertebral artery passage through the foramen transversarium and posterior fossa circulation is well outlined. The bony osteophytic processes around the foramen transversanum may occasionally encroach on the passing vertebral arteries to cause spasms and compromise the posterior fossa circulation.
Blood test including FLP, FBS, EUCR, FBC were all within acceptable limit.
Following clinical and radiological examination, the diagnosis above was made and the management plan outlined.
· Tab Aspirin 75mg daily.
· Philadelphia neck collar.
· Tab Stugeron 15mg only when needed.
· Tabs Neurobion 1 daily.
· Green tea containing senna
He was advised to stop driving and will be reviewed again in 3 months (2nd, May 2023)
Please revert, if need be, for further clarification
Dr. Halima Ibrahim
For Team Wellington Clinics.