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Cough-induced hemiparesis: an unusual manifestation of cord compression
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  1. Karim Mahawish
  1. Older Person Rehabilitation Services, Rotorua Hospital, Rotorua, New Zealand
  1. Correspondence to Dr Karim Mahawish, kmahawish{at}doctors.org.uk

https://doi.org/10.1136/bcr-2016-215537

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    Description

    A 67-year-old woman presented with a 1-year history of recurrent episodes of simultaneous left arm and leg weakness and numbness. Each episode would last a matter of seconds and was always precipitated by coughing or sneezing. She was asymptomatic between episodes. Physical examination demonstrated a normal cardiorespiratory assessment, while examination of the neurological system demonstrated normal tone, power and sensation with generalised brisk reflexes and equivocal plantars.

    Cervical spine X-ray performed in extension (figure 1) demonstrated an enlarged predentate space (distance between the anterior surface of the dens and the posterior surface of the tubercle) at C1, measuring 7.3 mm (normal distance ≤3 mm), and a narrowed spinal canal measuring an anteroposterior (AP) distance of 8.4 mm (normal AP size ∼17 mm, relative stenosis defined as 10–13 mm and absolute stenosis <10 mm). These findings were in keeping with atlantoaxial instability. Cervical spine X-ray in flexion demonstrated further narrowing of the spinal canal at C1 (figure 2). Sagittal MR T2 scan of the cervical spine demonstrated a posteriorly displaced peg with narrowing of the spinal canal at the C1 level to an AP dimension of 6 mm with likely compression of the cord (figure 3). MRI T2 axial slices through the cervical cord demonstrated left hemicord oedema (figure 4), accounting for the patient's predominantly left-sided symptoms. The patient underwent a C1/2 vertebral fusion (figure 5) and has remained asymptomatic since.

    Figure 1
    Figure 1

    Lateral C-spine X-ray in extension demonstrating an enlarged predentate space at C1, measuring 7.3 mm, and narrowed spinal canal measuring an anteroposterior distance of 8.4 mm.

    Figure 2
    Figure 2

    Lateral C-spine in flexion demonstrating further narrowing of the AP distance at C1. AP, anteroposterior.

    Figure 3
    Figure 3

    Sagittal MR T2 of the cervical spine demonstrating cord compression at the C1 level.

    Figure 4
    Figure 4

    Axial MR T2 of the cervical spine demonstrating cord compression and left hemicord oedema.

    Figure 5
    Figure 5

    Lateral post-operative C-spine X-ray with fixation screws through C1/2.

    Learning points

    • Transient ischaemic attacks or, less commonly, cerebral microbleeds, are more widely recognised causes of transient sudden onset focal neurological deficits. Other causes include focal seizures and metabolic derangements.

    • Though uncommon, cord compression may present with transient unilateral signs and should be suspected when neurological symptoms are precipitated by sudden head movements.

    • Patients presenting with recurrent focal neurological deficits should be admitted for urgent investigations as they are frequently associated with significant morbidity and mortality.

    View Abstract

    Footnotes

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.