Case study - Inconsistent symptoms in an elderly lady

Neurological symptoms after musculoskeletal problems made Dr Tillman Jacobi investigate further.

The patient had neck pain and restricted shoulder movement
The patient had neck pain and restricted shoulder movement

An 81-year-old temporary resident presented with a three-week history of neck and shoulder pain.

There was no apparent cause and her own GP had given her tramadol 100mg and paracetamol four times a day, as well as ibuprofen 400mg three times a day and diazepam 10mg at night. This mix controlled the pain but made her - unsurprisingly - tired and constipated.

Normally she did not take any medication; she had never smoked and was usually well.

Musculoskeletal pain
The patient complained of increasingly restricted movement in her left shoulder without any noticeable weakness or altered sensation in her limbs.

On examination, she had very tense and tender muscles over her neck and left shoulder area. She could lift her arm only up to about 40 degrees in all directions, with normal internal and external rotation. Neurology was normal.

As this appeared to be musculoskeletal with some side-effects from current treatment, it was decided to divide and spread the evening dose of diazepam as a 2mg tablet through the day as needed, and give laxatives.

I considered physiotherapy, but this seemed impractical as she was only planning to stay with her relatives for another week or so.

Chest X-ray
Five days later, she returned having had a private appointment with a local chiropractor who suggested an X-ray of her shoulder. She mentioned then that walking and breathing had become more difficult with the reduced arm movement, which sounded surprising. She denied any chest pains, palpitations and cough or any fever.

She had managed to reduce the diazepam and tramadol in the meantime and her bowel movements had improved. Her chest sounded clear with good overall air entry; pulse and BP were normal but she looked altogether a little more pale and tired than before.

As she had decided to stay in the area until she felt better, it was decided to send her for an X-ray of her chest and left shoulder and for some basal blood tests.

The X-ray was normal, the bloods only showed a mildly elevated ESR of 55 and CRP of 60; all the rest including FBC, LFT and renal function were normal.

Inconsistent symptoms
The next day she called for a home visit. The neck pain had improved but there was a new problem: overnight, for no obvious reason, she had developed a weakness, mainly in her proximal left arm and some problems with the coordination of her left leg. However, the sensation and power in her left forearm and leg appeared completely normal.

She was unable to abduct or elevate her arm and could not hold it up at all on passive movements. Her mobility had become somewhat unsteady. Her speech, cranial nerves and reflexes - including plantars - were normal, and BP and pulse remained normal.

The findings were puzzling and did not clearly indicate a cardiovascular event.

I discussed the problem straight away with the medical registrar to clarify whether I should admit her for neurological investigations or via orthopaedics, as the original problem had been musculoskeletal. We agreed on an orthopaedic review that lunchtime for a possible further referral if necessary.

Compressed cervical spine
A CT scan of her neck later that day revealed multiple metastases from an unknown and otherwise asymptomatic primary.

Spinal cord compression of the cervical spine as the presenting problem in cancer is fairly uncommon but an important emergency. Prompt referral of patients with strange, inconsistent neurological symptoms is essential to potentially reduce the occurrence of severe but preventable complications in these cases.

The patient was eventually found to have a non-small cell carcinoma of the lung. The most common cancers to metastasise into the spine and bones are breast, lung, prostate and multiple myeloma. In up to 30 per cent of patients, the neurological symptoms are the first sign and, in half of those patients, the primary site remains unclear.

In this case the tumour had already progressed considerably so that she could only be considered for palliative treatment. A one-off treatment of radiotherapy to her spine relieved the pain considerably for the meantime.

  • Dr Jacobi is a salaried GP in York.

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