History:
A 49 year old male, right hand dominant, referred for evaluation of right sided pectoralis weakness and atrophy first noted incidentally 2 months prior at routine physical. He subsequently noted weakness as he was no longer able to do bench press or even a single push-up which were standard exercises in his workout routine. He denied any history of specific injury or inciting event. Further questioning revealed numbness of the 2^nd and 3^rd fingers on the right. Notably he did not have any neck or shoulder pain.
Physical Examination:
Visual inspection revealed right sided pectoralis atrophy and winging of the inferior border of the scapula on the right. There was no tenderness to palpation in the cervical spine or shoulder girdle. There was full active cervical and shoulder range of motion without pain. Strength testing was normal and symmetric aside from weakness with forearm supination on the right compared to the left. Spurling test of the cervical spine was negative bilateral. Patient noted mild sensory deficits in the 2^nd and 3^rd digits on the volar aspect on the right. Normal radial and ulnar pulses bilateral.
Differential Diagnosis:
1)
Pectoral nerve entrapment
2)
Brachial plexopathy
3)
Cervical radiculopathy
Test and Results:
EMG/NCS
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Electrodiagnostic evidence of multiple right cervical radiculopathy, mostly involving C5 and C6 roots. Incidental finding of mild right ulnar neuropathy.
MRI C spine
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Right-sided hypertrophic changes are seen about the Luschka joints at C3-C4, C5-C6 and C6-C7. Most prominent at C5-C6 where there is moderate to severe narrowing. No evidence of disc herniation, canal stenosis or cord effacement.
Final Working Diagnosis:
Cervical radiculopathy, primarily of the C6 nerve root. As the imaging findings did not fully correlate with physical exam findings and EMG findings, patient was referred to neurosurgery for consultation and second opinion which is currently pending.
Treatment and Outcomes:
Provided neurosurgery recommends non-operative treatment patient will be referred to physical therapy to regain appropriate strength in hopes of returning to his prior workout routine.