30 year-old woman is involved in MVA in which she is stopped and struck from behind by car, whose estimated speed is 5 mph. The next day her neck is stiff and sore.

Exam

normal motor, reflex, and sensory exam
neck - loss of cervical lordosis
        - trapezius tenderness
        - pain on lateral rotation and flexion

Treatment with pain medication, muscle relaxants and NSAID is associated with symptom resolution in 3 weeks.

One year later neck pain recurs and she notes disequilibrium.

NE

bilateral plantar extensor responses
Cerebellar ataxia
Bilateral internuclear ophthalmoplegia

Images

Questions:

1. What is mechanism of initial symptoms following the accident?
   
   
2. What is mechanism of new symptoms?
   
   
3. What does MRI show?
   
4. Is there a single location in neuro-axis which can explain constellation of signs.

    

One year later she reports pain in her left eye and decreased visual acuity in her left eye.

New findings:

L    afferent pupillary defect
L    optic pallor
Left VA of 20/30 and right 20/15
Superior bitemporal quadrantopisa

1. What is possible explanation of this? (Clue: do not jump to a fast conclusion and review MRI carefully!).
   
2. What are MRI findings?
   
3. What is most sensitive and also what is most specific test for multiple sclerosis?
   
4. How should this patient be treated?

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Films C-14 - Revised 6/21/2005