Progressive Weakness After Cervical Decompression
A 58-year-old man underwent C5–C6 anterior cervical discectomy and fusion 10 days ago for myelopathic symptoms. Preoperatively he had brisk reflexes and a positive Hoffmann sign but was ambulating independently. He now presents with new bilateral hand clumsiness, worsening gait, and tingling in both hands. Exam shows 4/5 deltoids and biceps bilaterally, 3/5 wrist extensors, hyperreflexia at the knees, and a spurious extensor plantar response on the left. Temperature 37.9°C, HR 96, BP 148/88. Surgical site is clean and dry. He is on enoxaparin prophylaxis and a hard cervical collar. He asks whether this is just postoperative swelling and whether he can start outpatient PT next week.
1. What is your immediate priority, and what in the presentation drives it?
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This is a postoperative neurologic deterioration, not routine swelling. Priorities in order:
- Rule out a compressive/expanding lesion - epidural hematoma or seroma. The timing (days post-op), new bilateral upper-extremity weakness, ascending sensory change, and hyperreflexia fit a cord-compressive process. This is a surgical emergency until excluded.
- Urgent imaging: MRI of the cervical spine (or CT myelogram if MRI contraindicated) plus urgent neurosurgical contact. Do not remove the collar or manipulate the neck.
- Screen for cord injury mimics while arranging imaging: infection (fever, wound, labs), hypotension/hypoperfusion, and metabolic causes.
Key reasoning: new myelopathic signs after decompression mean the cord is being insulted again. The exam finding of a spurious extensor plantar and hyperreflexia localizes above the foramen magnum and argues against a peripheral cause. Outpatient PT is absolutely deferred.
2. He asks about starting outpatient physical therapy next week. How do you counsel him, and what is your rehabilitation plan for the next 48 hours?
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Counsel honestly: "Your symptoms suggest pressure on the spinal cord that needs to be checked today. Physical therapy is not safe until that is evaluated." Avoid false reassurance.
Next 48 hours:
- Maintain cervical collar and strict spinal precautions; log-roll, no axial loading.
- Bed rest with pressure-injury prevention; passive ROM only, no resisted neck motion.
- Monitor neuro status every 2–4 hours (strength, sensation, bowel/bladder).
- Anticipate possible urgent revision surgery; keep NPO status flexible.
After the acute question is resolved: graded rehabilitation, but only once imaging and the surgeon confirm no ongoing compression. If a hematoma is evacuated and deficits stabilize, begin early mobilization with a collar, isometric neck strengthening later, and functional gait training. Document the deterioration and your escalation clearly.
3. What red-flag findings would have changed your triage threshold earlier, and how would you document this encounter?
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Higher-acuity red flags: bowel or bladder dysfunction, saddle anesthesia, respiratory compromise, rapidly ascending weakness, fever with wound drainage, or hypotension. Any of these would prompt immediate emergency department transfer rather than same-day outpatient workup.
Documentation essentials:
- Time-stamped serial neuro exams with specific MMT grades and reflex findings.
- Explicit statement that this is a new postoperative deficit compared with baseline.
- The differential considered (hematoma, seroma, infection, cord edema, metabolic).
- Actions taken: imaging ordered, surgeon notified (name/time), patient instructed on return precautions.
- Patient's understanding and questions answered.
This protects the patient and demonstrates appropriate escalation of a time-sensitive complication.