Dr. Ambekar Sudheer
Neurosurgery
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
Six months ago, following a mild concussion, I started to have symptoms that were vaguely consistent with bilateral cervical radiculopathy. The cervical MRI showed severe stenosis and disc herniation at the C6-7 level going right and C5-6 going left. The worst symptoms were numbness, tingling, and weakness down the left arm. These symptoms really did not follow the C5-6 dermatome, however. They were all over the place in the left arm.
Six months later, the numbness and tingling have resolved. I feel stronger overall. However, I have had body-wide fasciculations for four months. And I can see wasting of the first dorsal interossei muscle of the left hand. It is subtle, but I notice it. I have trouble holding a pot or a phone with elbow bent past 90 degrees.
I have seen two neurologists including one neuromuscular specialist at an academic center. Both EMGs were clean. They needed the dorsal interossei muscle and all the other major muscles of the left arm. Clinical exams were also normal though benign fasciculations were noted. How do I know that I do not have ALS? What are the chances that these fasciculations are benign given the perceived weakness, atrophy, and fasciculations (body-wide)? How long does it take after the beginning of atrophy for an EMG to pick up ALS? What else could this be? Would not it be odd to develop ulnar neuropathy, worsening rotator cuff issues and bodyside fasciculations at the same time? I am not a doctor, but these seem like system wide problems.
Currrently, I am taking Lamictal, Zaleplon and Lipitor.
Hi,
Welcome to icliniq.com.
It is highly unlikely that the EMGs (electromyography) are clean in the presence of muscle wasting and fasciculations. I believe the symptoms and signs you are experiencing are due to cervical stenosis and not due to ALS. A C6-7 disc herniation can cause all the symptoms you have described. Is it possible for you to upload the MRI (magnetic resonance imaging) pictures?
In ALS (amyotrophic lateral sclerosis), usually, EMG findings precede clinical symptoms such as fasciculations and muscle wasting. This is also the case in radiculopathy due to cervical stenosis.
Patient's Query
Thank you doctor,
I have the MRI disc but not sure how to upload. The stenosis was C5-6 going to the left arm. Five months of PT have improved my overall strength with the left arm. However, the plate holding past ninety degrees and thumb to index wasting has worsened. I forgot to mention that my mother was diagnosed with ALS at the age of 75. I am a 41-year-old male.
Hi,
Welcome back to icliniq.com.
You can upload MRI images in Dicom format through icliniq. I will need to look at the MRI images to indicate whether the disc prolapse corresponds to the clinical features. If you have issues with uploading the images, the icliniq team will be happy to assist you.
Patient's Query
Thank you doctor,
I have attached the file. These are the C-spine images. Please note that the weakness I am experiencing is in my left arm, rotator cuff and holding items with the arm bent at more than ninety degrees. I see slight atrophy in the first dorsal interossei muscle.
Hello,
Welcome back to icliniq.com.
I have seen the MRI images. (attachment removed to protect patient identity).
There is indeed C6-7 stenosis on the left which can explain the symptoms and signs you are experiencing. However, the MRI is from the previous year. Since you have said in an earlier post that your symptoms have improved partially, I suggest you go for another MRI of the cervical spine at a good center (preferably 1.5T or 3T MRI) with a good resolution of images.
I do not see any changes within the cervical spinal cord or thinning of the cord which indicates atrophy of the cord.
Given that you have had a normal EMG in the past, I believe it is highly unlikely that you have ALS. The symptoms are most probably due to C6-7 disc herniation and spondylosis. The fasciculations are most likely benign and not indicative of ALS.
I suggest you continue physical therapy and do an MRI now. If it shows the same findings or better, we will reassess after three months.
Patient's Query
Thank you doctor,
Is the stenosis severe? The summary report only identified stenosis and herniated disc at the C5-6 level on the left side and C6-C7 on the right. I am not hunting for an ALS diagnosis. The sudden onset of fasciculations is very bothersome. I will get more images. Can C6-7 stenosis cause atrophy of that first dorsal interossei muscle?
Hello,
Welcome back to icliniq.com.
The stenosis is not severe but moderate. However, the images are not of good quality. (attachment removed to protect patient identity).
The sudden onset of fasciculations is very bothersome. I understand. Since the fasciculations have started only recently, it would be wise to do another MRI of good quality (preferably 3T). And yes, C6-7 radiculopathy can cause wasting of small muscles of the hand.
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Neurosurgery
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