Unmasking Intramedullary Spinal Cord Metastasis: A Case of Neck Pain Mimicking Spondylosis in a Cancer Survivor

Case Diagnosis: Intramedullary Spinal Cord Metastasis (IMSCM)

Case Description or Program Description: A 64-year-old woman with the history of small cell lung cancer was referred for evaluation of neck and shoulder pain during hospitalization for a small bowel obstruction after x-ray disclosed multilevel degenerative changes in the cervical spine and shoulder osteoarthritis. For the prior three months, she had reported worsening pain, characterized as a persistent dull ache with intermittent sharp surges, aggravated by movement and alleviated by rest. She denied pain radiating to the arms but acknowledged chronic sensory peripheral neuropathy from previous alkylating agent therapy.

Setting: Sports medicine clinic

Assessment/Results: Physical examination showed no swelling or warmth in the neck and shoulder. Tenderness was evident over the right trapezius and c-spine, accompanied by hyperreflexia and a positive Hoffman sign. Right shoulder abduction was mildly restricted by end-range pain, and bilateral upper extremity weakness was noted (4/5 in shoulder abduction, elbow flexion/extension; 3/5 in wrist extension, finger abduction/flexion). Pain was elicited with the lift-off test, subtle with empty can and resisted external rotation, while Hawkins and Jerk tests were positive; Spurling’s test was negative. Given the unexpected neurologic findings, an MRI of the cervical spine was ordered, revealing T2 hypodense lesions from C4-C7 and a syrinx spanning the craniocervical junction to T4. Intramedullary spinal cord metastasis (IMSCM) was suspected and later confirmed at the oncology clinic.

Discussion (relevance): This case highlights the risk of anchoring bias in sports medicine, where neck pain in a cancer survivor was nearly misdiagnosed. IMSCM, though rare, can mimic musculoskeletal pain with subtle neurologic clues like bilateral upper extremity weakness. MRI is critical when red flags are identified to ensure timely management.

Conclusions: Neck pain in malignancy patients requires a broad differential to include sinister etiologies like IMSCM. This case bridges oncology and musculoskeletal care, offering a key lesson for practitioners managing patients with cancer histories.