A case of functional deterioration in an older adult with CP: challenges in diagnosis, treatment and rehabilitation

Case Diagnosis: Cervical myelopathy in the setting of spastic/dystonic CP (GMFCS I-II)

Case Description or Program Description: A 78-year-old male with a history of spastic/dystonic CP (GMFCS I-II) presents with a subtle decline in motor function over 6-12 months, following a fall with facial trauma. Despite maintaining an active lifestyle, he experienced increased falls, worsening balance, fatigue, and slow overall decline.

Setting: Academic Institution

Assessment/Results: MRI of the cervical spine showed moderate to severe degenerative changes, multilevel spinal canal narrowing, and cord compression, worst at C3-C4. Surgical intervention was considered to prevent further compression; however, the decision was complicated by the challenge of attributing the deterioration to cervical myelopathy, aging with CP, deconditioning, or another unknown issue. Both patient and physicians hesitated due to factors like his potential response to major surgery, 10+ weeks with a neck brace, lengthy rehabilitation, age, deconditioning, psychosocial considerations, all in the context of CP. Ultimately, a C2-C6 fusion was performed. Rehabilitation after surgery was challenged by insurance denial for inpatient rehabilitation against medical recommendations. Consequently, the patient completed rehabilitation at a residential facility specializing in neurological rehabilitation. He eventually returned home and resumed his prior level of activity with slight improvement 18-weeks post-operation.

Discussion (relevance): In individuals with CP, cervical myelopathy may be unrecognized or ignored due to overlapping symptoms such as upper motor neuron abnormalities, gait disturbances, and upper limb weakness. In this case, decompressive cervical spine surgery prevented further decline and improved function.

Conclusions: The case highlights a positive patient outcome despite challenging decisions regarding diagnosis, care, and healthcare system barriers to care.