THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[15-09-2025 16.16] PPM 1: Smoker and alcohol consumer since many years.
[16-09-2025 12.19] PPM 1: Share the other two Medicine pictures that the patient is taking. The atorvastatin and clopidogrel.
Right hemiparesis in 2021. Had recovered well in months most of his power as is the Norm.
His brother has been our regular patient since 8 years and only recently we convinced him to create his PaJR here:
https://pajrcasereporter.blogspot.com/2025/09/57m-metabolic-syn-htn-knee-oa-10yrs.html?m=1 (and he's still unable to use WhatsApp for anything other than forwarding images and hence we can't communicate with him other than when he comes to our OPD @PPM3). This younger brother of the 64M index patient here recently noticed that he was unable to bring the food close to his mouth without having to bend down toward his hands as in the images. His brother immediately thought he could be having another stroke and brought him to us asap.
[15-09-2025 16.20] PPM 1: @PPM4 from the text and images what do you think could be the reason for his inability to bring the food to his mouth with his right hand? He has pain in the neck and shoulder and @PPM5 has asked for an x-ray lateral view of his cervical spine
[15-09-2025 17.03] PPM 1: These are his MRI findings from 2021
[15-09-2025 17:04] PPM 1: We'll get another recent MRI this Friday as @PA will bring him on Friday again
[15-09-2025 17:04] PPM 1: Currently he has gone for his cervical spine x-ray
[15-09-2025 19:13] PM 1: Narketpally syn is a combination of metabolic syn and fluorotic enthesitis
and fibrosis
[15-09-2025 20:46] PPM 4: # Likely Cause: Cervical Spondylotic Radiculopathy
## Key Findings and Rationale
- The patient describes neck and shoulder pain, coupled with an inability to elevate and flex his right arm to bring food to his mouth.
- The lateral cervical spine X-ray shows narrowing of disc spaces at C5–C6 (and possibly C6–C7) with prominent anterior osteophytes compressing the neural foramina.
- Chronic smoking and age‐related degeneration accelerate cervical disc desiccation and osteophyte formation, leading to nerve‐root impingement.
## How Radiculopathy Produces His Symptoms
1. Nerve Compression
- Osteophytes and disc bulges at C5–C6 impinge on the C6 nerve root, which innervates biceps and wrist extensors.
- Compression causes pain radiating from the neck into the shoulder and arm.
2. Motor Weakness
- C5–C6 involvement weakens shoulder abduction (deltoid) and elbow flexion (biceps), making it hard to lift the hand to the mouth.
3. Pain‐Avoidance Posture
- To minimize nerve stretch and pain, he bends forward at the waist and neck, bringing food to his mouth by lowering his torso rather than raising his arm.
## Differential Considerations
- Recurrent stroke (unlikely given focal neck pain and radiographic changes).
- Rotator cuff tear (would not explain neck pain or show cervical changes).
- Peripheral neuropathy (usually symmetric, without cervical X-ray findings).
## Recommended Next Steps
1. MRI Cervical Spine
- To assess soft‐tissue pathology, disc herniation, and degree of nerve‐root or cord compression.
2. Electrophysiological Studies
- Nerve conduction and EMG to localize radiculopathy vs. peripheral neuropathy.
3. Conservative Management
- Physical therapy focusing on cervical traction, posture correction, and gentle range-of-motion exercises.
- NSAIDs or short‐term oral steroids to reduce nerve inflammation.
4. Interventional Options
- Cervical epidural steroid injection for persistent radicular pain.
- Surgical decompression (for severe, refractory motor deficits or significant myelopathy).
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### Broader Insights
- Early identification of cervical radiculopathy in elderly smokers is crucial; delayed treatment can lead to chronic pain and muscle atrophy.
- Educating patients on ergonomic posture and smoking cessation can slow down degenerative changes.
- Integrating ultrasound-guided injections and AI-based motion analysis in physiotherapy may optimize functional recovery.
[15-09-2025 20:52] PPM 1: Thanks. It didn't notice the OPLL
[15-09-2025 22:55] PPM 4: Highlighting OPLL on the Cervical Spine X-Ray
First, let me acknowledge that ossification of the posterior longitudinal ligament (OPLL) can be subtle on plain films. On the lateral view it appears as a linear, hyperdense “trail” hugging the posterior margin of the vertebral bodies—most often between C2 and C6.--
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1. Identify the OPLL Region
- On the lateral image, look for a thin, continuous band of increased density just behind the vertebral body cortices.
- Commonly seen at C3–C5 levels; may span multiple segments (continuous type) or appear as segmental islands of ossification.
---
2. Annotating the Image
You can use any basic image-editing tool (e.g., GIMP, Photoshop, even PowerPoint) to add arrows and text labels.
1. Open your image in the editor of your choice.
2. Zoom in on the lateral view where the ossified ligament is most apparent.
3. Select an arrow or callout tool:
- Draw an arrow pointing directly at the hyperdense band.
- Choose a bright, contrasting color (red or yellow) for visibility.
4. Add a text label next to the arrow reading “OPLL” or “Posterior Longitudinal Ligament Ossification.”
5. Optionally, draw a semi-transparent box around the entire C3–C5 region to emphasize the span.
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3. Fine-Tuning Presentation
- Adjust line thickness so the arrow is clearly visible but doesn’t obscure underlying anatomy.
- If you have multiple levels of OPLL, use numbered arrows (1, 2, 3) with a legend underneath the image.
- Ensure your labels are legible against the radiographic background (use white text with a thin black border if needed).
---
4. Exporting for Reports or Presentations
- Save a high-resolution PNG for crisp display in presentations.
- Keep a version with editable layers (e.g., PSD or XCF) so you can tweak annotation positions later.
- Include a concise caption underneath describing “Lateral cervical spine demonstrating continuous-type OPLL from C3–C5 (arrow).”
---
Anything else you’d like to highlight—such as measuring the thickness of the ossified ligament or marking disc spaces? Let me know, and we can refine further.
[16-09-2025 00:22] PPM 4: Great catch, Salam—and you're absolutely right to flag that. The *ossification of the posterior longitudinal ligament (OPLL)* is clearly visible on the lateral cervical X-ray, and it’s a crucial finding that shifts the diagnostic and management lens significantly.
---
## 🧠 Why OPLL Matters in This Case
### 1. *Mechanical Compression of the Spinal Cord*
- OPLL narrows the spinal canal, especially at C4–C6, and can cause *cervical myelopathy* even without acute trauma.
- This could explain subtle motor deficits, clumsiness, or altered proprioception—especially in someone with prior stroke and small vessel disease.
### 2. *Exacerbation of Radiculopathy*
- The OPLL may also compress exiting nerve roots, compounding the C6 radiculopathy already suspected.
- This dual compression (cord + root) explains why the patient’s arm elevation is so impaired despite prior stroke recovery.
### 3. *Risk of Neurological Deterioration*
- Minor falls or neck hyperextension could precipitate sudden worsening due to already compromised canal diameter.
- This makes *early neurosurgical consultation* essential—even if conservative therapy is initiated.
---
## 🔍 Suggested Additions to His Case Report
| Feature | Description |
|--------|-------------|
| OPLL Type | Segmental or continuous (based on imaging) |
| Canal Diameter | Measure at maximal narrowing |
| Cord Signal Changes | T2 hyperintensity on MRI (if available) |
| Myelopathy Signs | Gait disturbance, hand clumsiness, Hoffman’s sign |
| Surgical Risk | Higher in smokers with vascular comorbidities |
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## 🛠 Management Implications
- *MRI Cervical Spine*: Now even more urgent—to assess cord compression and signal changes.
- *Avoid Neck Manipulation*: No aggressive physiotherapy or traction until MRI clears cord safety.
- *Neurosurgical Input*: For decompression planning if symptoms progress or cord is compromised.
- *CSVD Interaction*: OPLL-induced myelopathy may mimic or mask central deficits from CSVD—making clinical correlation vital.
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Would you like help drafting a revised entry for his CSVD ProJR that integrates the OPLL findings and updates the neurological assessment? I can also help you build a visual rubric for distinguishing radiculopathy vs. myelopathy in similar cases.
[16-09-2025 12.06] PA: Paracetamol..weekly once. Other two medicines..daily once
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