Introduction: Spinal arteriovenous malformations (AVMs) are rare neurologic lesions composed of abnormal blood vessels. The clinical symptoms associated with this pathology are extremely variable and may range from diffuse pain to progressive myelopathy and subsequent muscle weakness. To inhibit potential disease progression and neurological deterioration, early recognition of these lesions are important. In this report we present the case of an adolescent male athlete with cervical myelopathy secondary to a vertebral artery AVM. We discuss the need for specialist referral to aid with the initial diagnosis and guidelines for return to play. Case Report: A 19-year-old male athlete presented to clinic with a four-month history of progressive, generalized weakness in his bilateral upper extremities and chest. He noted difficulties bagging groceries at work and complained of arm weakness during basketball practice. He denied any recent injury and his review of symptoms was negative. His past medical history, family history, and social history were notable only for sickle cell trait. Physical examination at the initial visit showed no abnormalities; specifically, neurologic and musculoskeletal examinations were normal. Laboratory screening was negative for hematologic, infectious, endocrine, and autoimmune conditions, but was notable for an elevated creatine phosphokinase at 300 units/L (normal: 30-200 units/L). An outside neurologist was consulted after three visits with a general practitioner. The neurologist noted bilateral, symmetric upper extremity motor weakness (4/5) on examination. He then ordered a cervical spinal MRI with contrast, which showed an AVM of the epidural spinal space from C1-C5 and associated compression of the left side of the spinal cord (Fig 1). Subsequently, the patient was referred for neurosurgical treatment by coil embolization of the AVM. On post-procedure day one, the patient noted almost immediate improvement in upper extremity muscle control. He was discharged home on a regimen of physical and occupational therapy. The patient’s upper extremity strength progressively returned to baseline (5/5) over the next few months, and he returned to basketball within two months of treatment. Discussion: This case emphasizes the need for early neurologist referral to address weakness of unknown origin in the adolescent athlete. In this case, the diagnosis was only suspected based on a thorough neurological exam performed by a consulting neurologist and subsequent imaging findings. Furthermore, this case highlights the lack of specific return to play guidelines for this condition. In lieu of diagnosis-specific guidelines, the provider is left only with general return to play guidelines - no pain, full range of motion, full (5/5) strength, and full neurologic function. Conclusion: When treating an athlete with weakness of unknown origin, early neurologist referral is necessary for diagnosis and treatment. General return to play guidelines should be followed in lieu of diagnosis-specific guidelines.
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Council on Sports Medicine and Fitness|
August 01 2019
Cervical Myelopathy due to a Spinal Arteriovenous Malformation in an Adolescent Athlete
Jesse P. Robinette, BA;
Jesse P. Robinette, BA
Vanderbilt University School of Medicine, Nashville, TN
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Neerav A. Desai, MD
Neerav A. Desai, MD
Vanderbilt University School of Medicine, Nashville, TN
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Pediatrics (2019) 144 (2_MeetingAbstract): 178.
Citation
Jesse P. Robinette, Neerav A. Desai; Cervical Myelopathy due to a Spinal Arteriovenous Malformation in an Adolescent Athlete. Pediatrics August 2019; 144 (2_MeetingAbstract): 178. 10.1542/peds.144.2MA2.178
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