Case history summary

Presenting complaints

• Burning tingling/paraesthesia began in both feet and gradually ascended upward, reportedly reaching the chest.
• Constipation present.
• Urination was documented as normal at the neurology visit.
• Neurological examination documented:
  • Bilateral lower-limb spasticity
  • Brisk lower-limb deep tendon reflexes
  • Sensory level around T6
  • Upper-limb biceps/supinator reflexes normal; triceps reflex absent
• These findings indicate an upper motor-neuron spinal cord syndrome (myelopathy) rather than isolated peripheral neuropathy.

MRI findings

1. C5-C6
   • Disc bulge with right paracentral/right foraminal herniation, osteophytes, and posterior longitudinal ligament thickening.
   • Indentation of the anterior thecal sac and ventral spinal cord.
   • Bilateral C6 nerve-root involvement, greater on the right.
   • Subtle T2 hyperintense spinal-cord signal at C5-C6, reported as suspicious for early compressive myelopathy.
2. C6-C7
   • Disc bulge with posterocentral/right foraminal protrusion.
   • Contacts the front of the cord and affects the C7 roots, especially right.
3. C4-C5
   • Disc bulge/osteophytes contacting the ventral cord, without meaningful foraminal narrowing.
4. Thoracic and lumbar screening
   • D4-D5 ligamentum flavum thickening indenting the thecal sac and cord dorsolaterally.
   • L4-L5 disc bulge with mild bilateral foraminal narrowing.
   • Thoracic cord and conus described as normal.

Clinical impression

Priority management

Do this before routine physiotherapy

• Whether the cord compression is responsible for the neurological deficits
• Spinal stability
• Whether decompression surgery is indicated
• Whether a cervical collar is appropriate and, if so, what type and for how long
• Permitted mobility and rehabilitation restrictions

Go to the emergency department immediately if any of the following occurs

• New or rapidly worsening leg weakness, falls, or inability to walk
• New hand clumsiness, weakness, numbness, or loss of dexterity
• New urinary retention, urinary/bowel incontinence, or saddle/perineal numbness
• Rapidly ascending numbness, chest tightness from sensory loss, or new breathing difficulty
• Severe new neck/back pain, especially after a fall or sudden neck movement

Physiotherapy protocol

Important safety statement

Phase 1: Until spine-surgeon review and clearance

Goals

• Prevent falls, pressure injury, deconditioning, constipation complications, and loss of joint range.
• Maintain safe functional mobility without provoking cord symptoms.
• Monitor for neurological deterioration.
• Educate patient and family.

Precautions and contraindications

• Cervical spinal manipulation or mobilization
• Cervical traction
• Forceful massage around the neck
• End-range neck flexion, extension, rotation, or repeated neck movements
• Heavy lifting, resisted overhead exercise, push-ups, sit-ups, running, jumping, or high-impact activity
• Aggressive hamstring/hip stretching if it increases tingling, spasticity, or pain
• Unsupervised walking, stairs, or balance tasks if gait is impaired

Safe interventions, if symptoms remain stable

1. Positioning
   • Keep the neck in a comfortable neutral position.
   • Avoid prolonged neck flexion during mobile-phone use, reading, or pillow stacking.
   • Change position at least every 2 hours if mobility is limited.
   • Use a firm chair with armrests for transfers.
2. Bed mobility and transfers
   • Teach log-rolling: move shoulders and hips together, avoid twisting the neck/trunk.
   • Sit up gradually: lying to supported sitting, then standing only if there is no dizziness, worsening tingling, pain, or weakness.
   • Use assistance or a walking aid if there is imbalance.
3. Lower-limb range of motion
   • Gentle, pain-free active or active-assisted range of motion for hips, knees, and ankles.
   • 10 repetitions each, 1-2 times/day.
   • Stop if spasticity, numbness, or pain worsens.
4. Circulatory exercises
   • Ankle pumps and toe movements: 10-20 repetitions hourly while awake, provided there is no medical contraindication.
   • Monitor for calf pain, swelling, chest pain, or breathlessness, which need urgent medical assessment.
5. Respiratory exercises
   • Diaphragmatic breathing: 5-10 slow breaths, 3-4 times/day.
   • Supported coughing if secretions are present.
   • Escalate urgently for breathlessness, weak cough, or new chest symptoms.
6. Spasticity management
   • Slow, comfortable limb positioning.
   • Avoid rapid movements and triggers such as pain, constipation, tight clothing, skin irritation, infection, or a full bladder.
   • Document triggers and communicate them to the neurologist/spine team.
7. Constipation management
   • Coordinate with the physician regarding a bowel regimen.
   • Adequate fluid intake only if not medically restricted.
   • Regular toilet timing, foot support, and avoidance of straining.
   • Seek review if constipation worsens, there is abdominal pain/vomiting, or urinary symptoms arise.

Monitoring at every physiotherapy session

• Lower-limb power and ability to stand/walk
• Spasticity/tone
• Sensory symptoms and sensory level
• Balance and falls
• Pain score, particularly neck/back pain
• New hand symptoms
• Bladder/bowel changes
• Orthostatic symptoms and vital signs when mobilizing

Phase 2: After surgeon clearance, and if non-operative treatment is selected

Components

1. Gait and balance retraining
   • Parallel bars or close-guarded walking initially.
   • Weight shifting, controlled sit-to-stand, turning practice.
   • Walking aid prescription if needed.
   • No dual-task or challenging balance work until basic gait safety is established.
2. Lower-limb strengthening
   • Sit-to-stand from an elevated chair.
   • Supported mini-squats only if cleared and symptom-free.
   • Hip abduction/extension and knee-extension exercises with low resistance.
   • Begin with 1 set of 8-10 repetitions and progress gradually.
3. General conditioning
   • Seated pedal exerciser or short, supported walking intervals.
   • Begin 5-10 minutes, increasing according to symptoms and fatigue.
   • Avoid jarring or impact exercise.
4. Upper-limb conditioning
   • Light functional exercises below shoulder level with the neck neutral.
   • Do not use heavy resistance or overhead loading without specific clearance.
5. Education
   • Fall prevention and home safety.
   • Avoid abrupt neck movements.
   • Maintain medication adherence and scheduled neurological/spine follow-up.
   • Family education about red-flag symptoms.

Phase 3: Post-operative rehabilitation, if decompression/fusion is performed

• Wound and pain monitoring
• Safe bed mobility, transfers, and walking
• Prevention of chest complications, DVT, pressure injury, and constipation
• Gradual gait, balance, lower-limb strengthening, and functional independence training
• No neck manipulation or unapproved loading

Additional medical issues to follow up

• HbA1c approximately 6%
• Total cholesterol approximately 212 mg/dL
• Vitamin D3 approximately 14.3 ng/mL, which is low