An 82-year-old man presented to the emergency department with chief complaint of nonproductive cough, chest congestion, subjective fevers, hoarseness, and shortness of breath on ambulation for 2 days. He had chronic mild neck pain, which had been treated conservatively for the past 10 years. The patient had a history of 35 pack-years of smoking, which was discontinued 30 years prior to presentation. His medical history included hypertension, type II diabetes mellitus, and peripheral vascular disease with claudication, benign prostatic hypertrophy, colonic polyps, and multifocal osteoarthritis.\nOn examination, the patient had a grade 3/6 systolic murmur and decreased breath sounds at the bases bilaterally. Additionally the patient noted a 6-month history of unstable gait and loss of hand dexterity as well as bilateral upper extremity numbness and pain. Spine examination revealed decreased cervical range of motion. Neurologic examination revealed diffuse upper extremity weakness and hyperreflexia in the upper and lower extremities. He had negative Hoffman and Babinski signs. He then underwent an extensive metabolic workup, which revealed an elevated white blood cell count, elevated troponins, hyponatremia, and elevated blood glucose. Auxiliary tests included an abnormal electrocardiogram as well as elevated right hemidiaphragm with full inspiration on chest radiograph.\nThe patient was admitted to the hospital with persistent dyspnea. On hospital day 3, he underwent cardiac catheterization, which revealed extensive stenosis of the major coronary arteries, which was believed to be the main cause of his dyspnea. On hospital day 5, he underwent triple coronary artery bypass grafting. Despite the cardiac surgery, the patient's dyspnea did not improve. In addition, he developed new complaints of generalized weakness. He continued to complain of chest discomfort as well.\nMagnetic resonance imaging (MRI) and radiographic imaging of the cervical spine revealed extensive multilevel degenerative spondylosis with moderate to severe central canal narrowing from C2 to C7 and myelomalacia (\n). The patient underwent C2–C6 laminectomy and instrumented fusion with local autograft (\n). Lateral mass screws were utilized in the subaxial spine and pedicle screws were utilized at C2. Dome laminectomy was performed at C2. After surgery, the patient had gradual relief of dyspnea as well as improvement of strength. At 12-month follow-up, the patient was ambulating well and had improved neck pain. The dyspnea was completely resolved. His neck disability index had improved from 38% preoperatively to 30% at 1-year follow-up. The patient's chest X-rays showed that the right hemidiaphragm returned to its normal position.
A sixty-year-old female presented with intermittent shortness of breath happened in the morning of the day. She was a patient with chronic rheumatoid arthritis (RA) and was regularly followed in the rheumatologic clinic. During the past two weeks, she also complained of progressive numbness over bilateral hands and feet. Since the symptoms were not resolved by her daily medications and became more severe in the evening, she was brought to the ED for further evaluation.\nAt the ED, the patient was ambulatory, cooperative, and in mild distress, complaining of shortness of breath. Her vital signs were temperature 36.8°C, pulse rate 110 beats/min, respiratory rate 24 breaths/min, blood pressure of 168/81, and pulse oximetry 97%. Breathing sounds were normal without crackles or wheeze while auscultation. Other physical examination was unremarkable. Arterial blood gas was obtained and the data were within normal range. Because of the elevated D-dimer level, computed tomography of the chest was arranged to rule out the pulmonary embolism, but there was no significant finding.\nThe patient felt better after the use of oxygen during observation. However, reviewing of the medical records indicated the X-ray of the cervical spine was taken one week ago for the evaluation of limb numbness, and the increased distance at atlantoaxial space was noted (). Magnetic resonance imaging of the cervical spine was arranged and atlantoaxial subluxation with acute cervical spinal cord compression over C1-C2 level was found. The neurosurgeon was consulted and surgical intervention was suggested. However, the patient refused operation and conservative treatments with neck immobilization, and steroids were initiated during hospitalization. The patient was discharged 5 days thereafter with preserved neurologic function.