Aforty-one-year-old woman presented with an eight-month history of nausea
and abdominal pain. The medical history was remarkable for a herniated
cervical disc at the C5-C6 level, which had been successfully treated
nonoperatively. Previous surgical procedures included an appendectomy,
excision of a uterine fibroid, and a left oophorectomy. She denied any history
of trauma, gastrointestinal disease, or unresolved pelvic disease. She smoked
one pack of cigarettes per day and denied alcohol consumption. She was
employed as a health-care professional.
The patient presented with pain that was localized to the middle parts of
the abdomen and back; the pain was episodic in nature and was unrelated to
meals. Although she complained of severe nausea, she denied vomiting,
constipation, diarrhea, weight loss or gain, and appetite change. She also
denied having fever, chills, and other systemic symptoms. A thorough
gastrointestinal workup was performed. The results of liver-function tests
were normal, a right upper quadrant ultrasound study was remarkable only for a
renal cyst, and a cholecystokinin technetium 99-labeled iminodiacetic acid
(CCK 99mTc-HIDA) scan showed a somewhat depressed gallbladder
ejection fraction. Given the equivocally positive results of the
cholecystokinin technetium 99-labeled iminodiacetic acid scan and
progressively debilitating nausea and abdominal pain, the patient underwent a
laparoscopic cholecystectomy. However, she had no resolution of these symptoms
following the procedure. A gastroenterologist performed a nuclear gastric
emptying study, the results of which were normal. Before consideration was
given to endoscopic retrograde cholangiopancreatography, and given the history
of cervical disc herniation, a magnetic resonance imaging study of the
thoracic spine was performed and the patient ultimately was referred to the
orthopaedic spine service for consultation.
At the time of presentation to the spine clinic, the patient also
complained of difficulty with coordination and "jumpy feelings" in
her legs. Physical examination demonstrated no tenderness to palpation of the
spine. Neurological evaluation revealed a slightly wide-based gait and
hyperreflexia of both lower extremities. The Babinski sign was negative. The
patient had decreased sensation to pinprick along the T9 and T10 dermatomes on
the right side and subjective hypesthesia to pinprick in both lower
extremities. The motor and sensory examination of both upper extremities
revealed normal findings. Magnetic resonance imaging showed a large central
disc herniation with compression of the thoracic spinal cord at the T9-T10
level (Fig. 1).
The patient underwent transthoracic excision of the herniated
disc6
(Fig. 2). She had complete
relief of the nausea and abdominal pain postoperatively. She returned to her
job as a health-care professional three months after surgery. Follow-up
radiographs that were made one year postoperatively demonstrated normal
alignment of the spine without evidence of instability. By one and one-half
years postoperatively, the patient continued to do well and had had no
recurrence of symptoms.