Case History:

52 yo male with work related neck pain

Contributed By:
Jennifer Illes, DC, MS
Case Presentation: Page 1 of 4

A 52 year-old Caucasian male came to the office with a complaint of neck pain and low back pain.  Due to the severity of pain in his neck, the initial focus of examination and treatment was based on this area.  The patient has had the neck pain since after a work-related 7-8 foot fall off a scaffold onto the ground on in 2008.   Currently, the pain radiates into the right hand, mainly into the pinky finger.  He rated the pain at 7/10 on a verbal analog scale on average and 10/10 on a verbal analog scale at its worst.   The patient also complained of a tremor in his left arm which appeared immediately after his work-related fall. Rest and ice seem to makes the pain better but not the numbness. Reading and bending his neck forward make the numbness and pain worse. Sleeping at night is bothersome but does not interfere with constant interruption of sleep.

Significant Past Medical History:

Mr. X lost consciousness after the work accident in 2008. He went to the hospital  for radiographs and treatment. Patient had a lumbar spine laminectomy in 2010. Left shoulder surgery 2009, and had a cast on his wrist for a month (all which were accident related).

Question: Based on this clinical history, what are some differential diagnosis you are considering?

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