Jack H. Deckard, M.D.
2025 East Newport Avenue, #140 
Milwaukee, WI 53211

RE: VINCENT CATALDI

Dear Dr. Deckard:

It was my pleasure to evaluate your patient on August 27,2003. He is a self-referred patient who carries a history of a C3-C4 myelopathy. As you know, he is a pleasant man with numerous congenital anomalies primarily affecting his right side. Approximately five years ago, he developed cervical and lumbar spine pain. He underwent an extensive oncologic workup and was found to have some fatty infiltrates on his vertebral bodies on MRI as a result of degenerative disease. An MRI scan and a complete neurologic workup by Dr. Wooten revealed pressure fracture at T9 and multiple pathologies from C2 to C6, degenerative and spondylolisthesis changes with central canal stenosis at C3 to C4. He complains of some dyscoordination, specifically, weakness of his hands and legs. This does not cause dysfunction upon ambulation. Rather. he has some increase of fall risk due to his instability and "dizziness." He reports back stiffness as an adolescent. However, he denies any ongoing back stiffness.

PAST MEDICAL HISTORY: Includes congenital deformities with fusions of the fingers of his right hand. In February of 2003, he developed a cyanotic right foot. He was evaluated in St. Mary's Emergency Room, where it is unclear what the eventual diagnosis was. Congenital deformities of the right foot. No previous history of coronary artery disease, thyroid disease, or diabetes mellitus.

PHYSICAL EXAMINATION: Blood pressure 142/81. In general, he is a well-appearing male who is very slender and raises his left shoulder in order to relieve pain in his neck. Skin: Without any psoriatic lesions, without any inflammatory lesions. HEENT: The neck demonstrates decreased range of motion. I did not stress the range of motion due to the patient's history of C3 myelopathy. Heart: Regular rate and rhythm; normal S I, S2 without any murmurs, gallops or rubs. Lungs: Clear to auscultation without any wheezes, rhonchi or rales. He did have some tenderness over the left posterior rib cage secondary to light touch. Abdomen: Soft:, nontender, nondistended without any hepatosplenomegaly. Extremity Examination: Reveals decreased range of motion of both shoulders to approximately 90°of abduction bilaterally. The elbows have full range of motion. No synovial swelling or tenderness. The wrists have full range of motion without any tenosynovitis. The MCPs are without any tenosyriovitis or synovial swelling as are the PIP and DIP rows. Lower Extremities: Reveal decreased range of motion at the hips bilaterally. There is a normal Schober's test, however. There is full range of motion at the knees with some mild crepitance. The ankles are without any tenosynovitis, the MTPs without any compression tenderness. Neuro Examination: The patient has diminished hand strength on the left in comparison to the right. There are some sensory deformities of the right hand. There are somewhat hyperret1exic reflexes at the patellar reflex and the ankle reflex.

Rheumatic Disease Center

Cataldi, Vincent 04/14/54 

Dr. Oelke

X-ray # : R26867

RB/s1b

DD: 08/28/03 DT: 08/29/03

Blount Orthopaedic Clinic, Ltd.
625 East St. Paul Avenue
Milwaukee, Wisconsin 53202

CHIEF COMPLAINT: Second opinion about neck.

HISTORY: Vince is a 49-year-old gentleman who is an old patient of mine. He is a very pleasant man who has numerous congenital anomalies, which have primarily affected his right side. He has apparently developed a myelopathy, which largely relates to a problem in his neck. During the process of workup, he was noted to have interosseous abnormalities in both the cervical and lumbar spine on MRI. Apparently, these were initially thought possibly to represent a multiple myeloma; however, after Bence Jones protein test and some others, he was felt not to have any sort of a neoplastic condition, but rather some fatty infiltrate in the vertebral bodies, as a result of degenerative disease. He has seen Dr. Jack Deckard, who has recommended a decompression and fusion at C3-4.

Vince brought copies of consultations with both Dr. Wooten and Dr. Deckard, suggesting that he indeed does have a significant myelopathy and that operation is suggested, probably an anterior decompression with fusion. Dr. Wooten sent a note to me in 01/03, indicating that an MRI scan of the thoracic spine did not demonstrate any lesion at T3 where one had been anticipated. There was a compression fracture at T9 that was not affecting adjacent neural structures, but in the cervical spine, he had severe multiple level pathology from about C2 to C6. This included, most significantly, degenerative change and spondylolisthesis with central canal stenosis at C3-4, where there was cord compression and signal abnormality in the central cord. Dr. Wooten felt that this explained the spectrum of the patient's complaints.

At this time, Vince does complain of some pain in the neck, occasional double vision, fatigue, but most specifically, weakness and discoordination in both his hands and his legs. He is here to have my opinion on whether or not the surgery should be done. He is interested in what the affects on adjacent joints will be and whether cervical surgery would affect his lumbar situation. He also wonders whether the abnormal areas in the vertebral bodies need to be assessed further. It seems to me that he has an obvious concern about the possibility of malignant disease there, even though the current feeling is that he has just some fatty infiltrate.

A letter to Dr. Wooten from Dr. Deckard on 07/29/03, indicates Dr. Deckard's concern about myelopathy at C3-4. He recommends surgical decompression and would probably favor an anterior decompression with arthrodesis and cervical plating, the main goal being prevention of progression of the patient's symptoms. He did indicate that there would the possibility of a repeat surgery or a nonunion. The use of allograft versus autologous bone was discussed. He also told the patient that there was increased risk of neurologic problems occurring as a result of a fall relative to the situation for someone with a normal cervical spine. Dr. Deckard recommended that the patient not wait an extended period of time before proceeding with the above recommended surgery.

I reviewed the MRIs and would agree that there is very significant stenosis at C3-4 and likely a myelopathic change in the cord at that level. The lumbar MRI shows relatively lesser changes with some stenosis at L4-5 and less at 3-4. There also is a suggestion of foraminal encroachment at L4-5 and 5-1 on the left. On both of these studies, he has some areas of hyperintense return in the vertebral bodies, which were interpreted as fatty infiltration. Please see also a letter from Dr. Deckard to Dr. Wooten, which is dated 06/16/03.

The MRI performed at Columbia Hospital on 01/29/03, was interpreted as showing possible multiple myeloma, whereas the later studies were said to show fatty infiltration. It is easy to see why the patient is concerned.

Vince brought laboratory work, which included normal serum albumin and total protein, bilirubin and direct bilirubin, AST, alkaline phosphatase, ALT, glucose, BUN, and creatinine. He also has normal calcium, electrolytes, and met-hemoglobin with CRP of 0.1 and a sed rate of 1 mm per hour. His H&H are 15.0 and 43.8. White count 7200 with normal differential.

Vince had multiple questions regarding the abnormalities in the bodies, the need for surgery, the use of allograft versus autograft, and his general nutritional status. I told him I felt that his nutritional status seems to be adequate, but he still should try to gain weight - he is very slender at this time. I also favor the use of autograft over allograft. I do think the surgery is important and should be done without undue delay. I do feel that he has concerns about the presence of a tumor in his bone. It might be well for him to see an oncologist to resolve his questions or concerns in that area. Vince seemed satisfied at the end and left with his MRIs for further consultation.

The total time spent discussing this with the patient was between 30 and 40 minutes and with the additional review of records, the total time was 45 minutes. WTD/ma/lk

Jack H. Deckard, M.D.
Neurological Surgery Consultants, Itd.

June 29, 2003

Marvin Wooten, M.D.
2025 E. Newport Ave. #210
Milwaukee, WI 53211

Re: Vincent Cataldi

Dear Marvin

Mr. Cataldi returned to the office for follow-up. At the present time, his complaints are approximately the same or maybe slightly worse. He states he has problems in the upper body and he states, "My hands don't work." The right hand is affected more than the left. The hands are weaker. He does note diplopia as previously noted at times. He has numbness in both hands and states he has difficulty buttoning his shirts. He states the weakness in his hands has been going on for approximately 3+ months. He has no symptoms of Lhermitte's phenomenon. The patient also states that his lower body is "pretty good now." He does have some pain in the legs. He states that he was born with a defect in his right lower extremity and that it was "backwards." He states that they "twisted it around slowly as I grew older." He states now, however, that the left foot seems to be affected. This does cause him some increasing problems.

The patient was also born with a congenital defect of the right hand and has had surgery for this. I believe the third through fifth digits were fused together at birth. I did review multiple radiographic procedures. Cervical spine x-rays including flexion and extension views revealed severe spondylogenic changes at multiple levels. He has marked spurring and disk narrowing. C3 is slightly anterior to C4 of approximately 3 mm. There is no change with flexion and extension.

I also reviewed an MR scan of the cervical spine and compared it to the films from January 2003. The overall changes are approximately the same. He has significant stenosis at C3-C4 from both anterior and posterior with abnormal signal within the cord. On the axial view, the defects seem mainly from anteriorly. He does not have significant stenosis of the canal at other levels. There is CSF anterior and posterior to the cord at other levels.

An MR scan done of the lumbosacral spine revealed some abnormal signal within the vertebral bodies of L4 and L5. There is a mild defect anterior to the theca at L4-L5 with some degree of stenosis. The alignment was intact. On the axial view, there is some generalized stenosis at the L4-L5 and to a lesser extent at L5-S1.

An MR scan of the brain with and without contrast was unremarkable. The patient did have an MR scan of the thoracic spine previously which was unremarkable.

On physical examination, he was alert and oriented. He had reasonable range of motion of his neck. He had reasonable strength of the deltoids, biceps and triceps, He did have atrophy of the intrinsics bilaterally and weakness of the grip and intrinsics bilaterally. He does have the congenital defect of his right hand. He had reasonably good strength in the lower extremities. His straight leg raising wash unremarkable. He had no ankle clonus. He was able to ambulate without assistance, although he had a mild degree of unsteadiness on turning. His Romberg's testing was negative. He had difficulties with tandem gait, and he stated this is mainly due to the congenital problems in his right leg. 

I did have a lengthy discussion with Mr. Cataldi including reviewing the films. He does have evidence of myelopathy and the abnormal signal within the cord at C3-C4. I would recommend surgical decompression of the area and in his case would probably favor an anterior decompression with arthrodesis and cervical plating. The main goal of the surgery would be to prevent his symptoms from increasing. Hopefully, however, he would gain some improvement in his complaints. I did extensively review the actual operation including the operative indications, expectations, alternatives and extensively reviewed the risks. I discussed the use of allograft versus autologous bone. He would need to be in a firm cervical collar for at least six to eight weeks after surgery. I did discuss with him also that he may need a posterior decompression at some point in time if he continues to have stenosis from posteriorly. He also is aware that he could develop problems at other levels. He asked about the potential danger of falling. I discussed with him that he certainly would have increased risk of increasing neurologic problems with a fall compared to someone with a more normal appearing cervical spine. I did recommend again that he not wait an extended period of time before proceeding with the above recommended surgery.

The patient understands the above and wants to consider the above discussion. He is to get back in touch with me if he wants to proceed with surgery or if he has any other questions.

Thank you again for allowing me to participate in his care.

Sincerely,

Jack H. Deckard, M.D.

JHD/midwest

DD: 07/29/03
DT: 07/31/03

cc: Robert Wetzler, M.D.

Addendum: I have also ordered a CT scan to be done without contrast of the cervical area for better bony delineation prior to proceeding with any surgery. The total length of this consultation was 40 minutes.

July 14, 2003
Dr. Jack H. Deckard - Scans

DEPARTMENT OF MEDICAL IMAGING
COLUMBIA HOSPITAL
2025 East Newport Avenue Milwaukee, WI 53211 (414)961-3300

FINAL RESULTS

RAD ORDER # :    90001     INV ORD # : 1
EXAMINATION:                MRI BRAIN COMBINATION 07/14/2003
PROCEDURE REASON:     MYELOPATHY

RESULT:

MRI OF THE HEAD WITH AND WITHOUT CONTRAST:

THE EXAMINATION IS DONE FOR EVALUATION OF MYELOPATHY.

SAGITTAL AND AXIAL T1, AXIAL AND CORONAL T2, AXIAL FLAIR AND T1 WEIGHTED IMAGES WERE OBTAINED. ADDITIONAL POST CONTRAST AXIAL AND CORONAL TI WEIGHTED IMAGES WERE PERFORMED.

THE VENTRICULAR SYSTEM AND SULCI ARE WITHIN NORMAL LIMITS. THERE IS NO EVIDENCE OF DEVELOPMENTAL ANOMALIES. THE MIDLINE STRUCTURES ARE NORMAL.

NO FOCAL LESIONS ARE IDENTIFIED. THERE IS NO EVIDENCE OF DEMYELINATING PROCESS OR EVIDENCE OF FOCAL MASSES.

AFTER ADMINISTRATION OF CONTRAST MATERIAL, THERE IS NO EVIDENCE OF ABNORMAL ENHANCEMENT.

WITHIN THE SUBCUTANEOUS TISSUES POSTERIORLY AT THE LEVEL OF THE OCCIPITAL PROMINENCE. THERE IS A 2 X 0.5 CM MASS-LIKE STRUCTURE WHICH IS WITHIN THE SUBCUTANEOUS TISSUES AND IS ADJACENT TO THE SKULL WHICH HAS HIGH SIGNAL ON T1 AND HIGH SIGNAL ON T2. THIS IS THOUGHT TO REPRESENT PROBABLY A SEBACEOUS CYST WITH CHOLESTEROL PRODUCTS GIVING HIGH SIGNAL ON BOTH T1 AND T2 WEIGHTED IMAGING.

IMPRESSION::
NO EVIDENCE OF INTRACRANIAL PATHOLOGY

RAD ORDER #: 90001        INV ORD # : 2
EXAMINATION:                MRI CERVICAL SPINE W/O CONTRAST 07/14/2003
PROCEDURE REASON:     MYELOPATHY

RESULT::

CERVICAL SPINE MRI WITHOUT CONTRAST:

THE EXAMINATION IS DONE FOR EVALUATION OF MYELOPATHY,

THERE IS SOME SWALLOWING ARTIFACT AND SOME MOTION ARTIFACT WHICH CAUSE SOME DEGRADATION OF THE AXIAL IMAGES.

THE MIDLINE STRUCTURES AND THE PARASAGITTAL STRUCTURES IN THE POSTERIOR FOSSA APPEAR UNREMARKABLE. THERE ARE SIGNIFICANT-AREAS OF HIGH SIGNAL INTENSITY THROUGHOUT THE CERVICAL SPINE INVOLVING C3, C4, C5, C6, AND C7. THESE ARE ALL CONSISTENT WITH AREAS OF FATTY INFILTRATION BECAUSE OF DECREASED SIGNAL WHEN FAT SUPPRESSION IS APPLIED. THESE ARE ALL CONSISTENT WITH DEGENERATIVE CHANGES WITHIN THE VERTEBRAL BODIES.

C2-3: AT THIS LEVEL, THERE IS A NORMAL APPEARING DISC. THE DISC SPACE IS WELL MAINTAINED.

C3-4: AT THIS LEVEL, THE DISC SPACE IS SLIGHTLY NARROWED. THERE IS A DIFFUSELY BULGING DISC. AT THIS LEVEL, THERE IS SIGNIFICANT FACET HYPERTROPHY, AND THE COMBINATION WITH THE MILD DISC BULGE CAUSES ENTRAPMENT OF THE CORD AT THIS LEVEL. THERE IS FLATTENING AND IMPINGEMENT OF THE CORD. JUST BELOW THIS LEVEL, THERE IS AN AREA OF FOCAL HIGH SIGNAL INTENSITY WITHIN THE CORD CONSISTENT WITH AN AREA OF MYELOPATHIC CHANGES.

C4-5: AT THIS LEVEL, THERE IS A DIFFUSELY BULGING DISC WITH AN ASSOCIATED POSTERIOR OSTEOPHYTE. THE DISC IS MINIMALLY BULGING. THE VENTRAL CSF SPACE IS MAINTAINED, ALTHOUGH NARROWED.

C5-6: AT THIS LEVEL, THE DISC SPACE IS MARKEDLY NARROWED. THERE IS A POSTERIOR BONY RIDGE THAT CAUSES SOME FLATTENING OF THE VENTRAL THECAL SAC BUT NO IMPINGEMENT OF THE CORD.

C6-7: AT THIS LEVEL, THERE IS DISC SPACE NARROWING. THERE IS A POSTERIOR OSTEOPHYTE AS WELL AS A DIFFUSELY BULGING DISC POSTERIORLY. ON THE RIGHT SIDE, PARTICULARLY ON THE SAGITTAL SLICE 10 OF THE T2 WEIGHTED IMAGES. THERE IS A FOCAL DISC HERNIATION. THIS IS NOT WELL VISUALIZED ON THE AXIAL IMAGES. THERE IS NO EVIDENCE OF MYELOPATHY.

IMPRESSION: MULTILEVEL DEGENERATIVE DISC DISEASE WITH AREAS OF BULGING AS WELL AS BONY OSTEOPHYTES, AS DESCRIBED ABOVE. THE BONY CHANGES ARE MOST PRONOUNCED AT THE C5-6 AND C6- 7 LEVELS. FOCAL DISC HERNIATION IS IDENTIFIED ON THE RIGHT SIDE AT C6-7 ON THE SAGITTAL VIEW ONLY. THE MOST PRONOUNCED LEVEL IS AT THE C3-4 LEVEL WHERE THERE IS A SLIGHT ANTERIOR SPONDYLOLISTHESIS OF C3 ON C4 WITH A DIFFUSELY BULGING DISC AND SIGNIFICANT FACET HYPERTROPHY. THE CHANGES CAUSE IMPINGEMENT OF THE CORD AS WELL AS INCREASED SIGNAL WITHIN THE CORD CONSISTENT WITH MYELOPATHY. THERE IS- MULTILEVEL NEURAL FORAMINAL NARROWING, PARTICULARLY BILATERALLY AT THE LOWER THREE CERVICAL LEVELS.

RAD ORDER # : 90001   INV ORD 3
EXAMINATION:          MRI LUMBAR SPINE W/O I CONTRAST 07/14/2003
PROCEDURE REASON:     MYELOPATHY

RESULT::

LUMBAR SPINE MRI WITHOUT CONTRAST:

THE EXAMINATION IS DONE FOR EVALUATION OF MYELOPATHY.

SAGITTAL AND AXIAL T1 AND T2 WEIGHTED IMAGES WERE OBTAINED.

THERE IS SLIGHT RETROLISTHESIS OF L5 ON S1. THERE IS INCREASED SIGNAL ON T1 AND T2 WEIGHTED IMAGING ALONG THE ENDPLATES OF THE L4-5 DISC SPACE AS WELL AS THE L5-S1 DISC

CATALDI, VINCENT J #660995
PAGE 3

SPACE CONSISTENT WITH FATTY DEGENERATIVE MARROW CHANGES. THE SPINAL CORD ENDS AT APPROXIMATELY THE L1 LEVEL.

L1-2: THE DISC IS NORMAL

L2-3: THE DISC IS NORMAL

L3-4: AT THIS LEVEL, THERE IS DISC DEHYDRATION. THERE IS A DIFFUSELY BULGING DISC AND MODERATE BILATERAL NEURAL FORAMINAL NARROWING. THE BULGING DISC DOES EXTEND INTO THE FORAMINAL REGIONS. THE BULGING DISC IS SLIGHTLY ASYMMETRIC IN A RIGHT PARACENTRAL LOCATION AND RIGHT FORAMINAL REGION.. THIS IS THOUGHT TO REPRESENT A SMALL DISC HERNIATION.

L4-5: AT THIS LEVEL, THERE IS DISC DEHYDRATION AND DISC SPACE NARROWING. THERE IS A DIFFUSELY BULGING DISC WHICH IS FAIRLY SYMMETRIC AND EXTENDS INTO THE FORAMINAL REGIONS BILATERALLY. THIS IS MUCH MORE PRONOUNCED IN THE LEFT FORAMINAL REGION AND IS CONSISTENT WITH A LEFT FORAMINAL DISC HERNIATION, AND THIS WOULD AFFECT THE EXITING NERVE ROOT. THERE IS SOME MODERATE SPINAL STENOSIS AT THIS LEVEL.

L5-S1: AT THIS LEVEL, THE DISC IS DEHYDRATED AND THE DISC SPACE IS NARROWED. THERE IS A DIFFUSELY BULGING DISC SIMILAR TO THE LEVEL ABOVE. IT IS MORE PRONOUNCED IN THE LEFT FORAMINAL REGION. THIS WOULD BE CONSISTENT WITH A FORAMINAL HERNIATION. THIS WOULD AFFECT THE NERVE ROOT THAT IS EXITED THROUGH THE FORAMINA. THERE IS BILATERAL FORAMINAL NARROWING WHICH IS FAIRLY SEVERE BILATERALLY AND PRIMARILY DUE TO THE INTERFACET DISEASE.

IMPRESSION::

MODERATE STENOSIS AT L4-5 WITH MILD STENOSIS AT L3-4. THERE ARE DIFFUSE BULGES AT L3-4, L4 -5, AND L5- S1 FOCAL DISC HERNIATION IS IDENTIFIED PRIMARILY IN THE FORAMINAL REGIONS AT L4-5 AND L5-S1: ON THE LEFT SIDE AFFECTING THE EXITING NERVE ROOTS.

TRANSCRIBED BY: LL/LL 07/14/2003 11:48AM
READING DOCTOR: BROGHAMMER, BENJAMIN G., MD
THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY:
BROGHAMMER, BENJAMIN G., MD

DEPARTMENT OF MEDICAL IMAGING
COLUMBIA HOSPITAL
2025 East Newport Avenue Milwaukee, WI 53211 (414)961-3300

FINAL RESULTS

RAD ORDER #:                   90001 INV ORD # 4
EXAMINATION:                CERVICAL SPINE COMPLETE 07/14/2003
PROCEDURE REASON:     MYELOPATHY

CERVICAL SPINE (FIVE VIEWS):

THE PATIENT IS HAVING LOSS OF MUSCLE CONTROL.

THERE IS AN ANTERIOR SPONDYLOLISTHESIS GRADE I OF C3 ON C4, AND GRADE 1 ANTERIOR SPONDYLOLISTHESIS OF C4 ON C5. THERE IS MODERATE DISC SPACE NARROWING AT C3-4 AND SEVERE DISC SPACE NARROWING AT C5-6 AND C6-7. POSTERIOR OSTEOPHYTES ARE IDENTIFIED OFF THE C3 VERTEBRAL BODY, C5 VERTEBRAL BODY, AND C6 VERTEBRAL BODY.

IMPRESSION::
THERE IS SEVERE DEGENERATIVE FACET DISEASE AT C2-3 AND C3-4, AND THERE IS BILATERAL NEURAL FORAMINAL NARROWING, MOST SEVERE ON THE LEFT SIDE AT C3-4, C5-6 AND C6-7.

TRANSCRIBED BY: LL/LL 07/14/2003 02:46 PM

READING DOCTOR: BROGHAMMER, BENJAMIN G., MD

THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED BY:

BROGHAMMER, BENJAMIN G., MD

Jack H. Deckard, M.D.
Neurological Surgery Consultants, Itd.

June 16, 2003

Marvin Wooten, M.D.
2025 E. Newport Ave. #210
Milwaukee, WI 53211

Re: Vincent Cataldi

Dear Marvin

Neurosurgical consultation was requested on this 49-year-old right-handed white male, who is a self-employed computer programmer, who presents with evidence of cervical myelopathy.

I am sure Mr. Cataldi's history is well known to you. He presents with complaints of pain in the upper as well as lower extremities as well as in the trunk. His complaints have been going on for several years. He states that initially he noted some discomfort in his left foot. He thought this was just related to changes in the foot itself. He does have some congenital abnormalities of his extremities. The pain subsequently began to involve more extensively the left leg and subsequently left torso. He is not certain of exactly how rapid the onset of his complaints were. He denied any trauma. He began to note come complaints on the right side approximately last November. He also has been complaining of some "noises" with neck movement. He also notes itching in his neck. He states that he had had difficulties with his right foot "forever." He notes more recent problems in his left foot. He was born with a congenital abnormality of his right foot which he described as a "clubfoot." This was reportedly not treated with surgery.

He does note that more recently his arms seem to be clumsy. He notes a clenching sensation in his distal upper extremities bilaterally. This initially started on the left but subsequently involved the right. He notes weakness of the distal upper extremities but not the proximal upper extremities. There is no change with Valsalva maneuvers. He is not certain whether his legs are weaker. He did have a period of both urine and stool incontinence, but this was variable, 18 to 24 months ago. His complaints lasted approximately six months. He states that overall it has been better.

The patient may have had an EMG in the past, but he is not certain. He has seen Dr. Dicus since the mid-1960s as Dr. Dicus was "our orthopedic doctor." The patient has noted low back pain for years but no neck pain in the past.

Mr. Cataldi also complains of visual problems which seem to be related to when his hands are bothering him. He states that at times he will have diplopia even with monocular vision.

I know on your evaluation you thought he was suffering from myelopathy. You initially thought this was at the T3 level. According to your initial evaluation, this occurred I believe in June 2002.

I did review an MR scan from Columbia Hospital in the sagittal views of the cervical spine as well as sagittal and axial scans in the thoracic spine. This was done with and without contrast. The study is dated January 29, 2003. On the lateral cervical view, there was significant abnormal signal at multiple vertebral bodies from C3 down to C7. There was spurring and significant decrease in the disk height at C5-C6 and C6-C7. The alignment was reasonably intact. There was decrease in the subarachnoid space posteriorly to a significant degree at C3-C4 and to a lesser extent at C4-C5. There was probable abnormal signal within the cord at C3-C4. There were some mild changes anteriorly of the vertebral bodies from C3-C4 down to C6-C7, but this was not overly impressive. There was no significant stenosis at the other levels. There were no axial scans. There was no enhancement appreciated. The thoracic spine was within normal limits.

The patient reportedly had a CT scan of his head at Froedtert Hospital sometime earlier this year. do not have this for review and do not know the exact reasons for this being ordered.

Past medical history and review of systems are quite complicated. He does have congenital defects of the right upper extremity as well as the lower extremities, again worse on the right than the left. He also has been complaining of some nausea for at least three years but significantly over the last several months. He was seen at the Froedtert Hospital Emergency Room earlier this year. He states he has an allergy to cholinesterase. He has had surgery in 1954 and 1966 for his right hand. Again, he states he was born with a deformity of his hands, worse on the right than the left, as well as the right foot. The patient also complains that his feet more recently have been "black and blue."

His father is living at age 86. His mother died at approximately age 75 of heart problems.

The patient is originally from New York. He is single and has no children. He is self-employed and states that he is unable to work much. He previously smoked one pack of cigarettes a day for 20 years but now decreased it to four cigarettes a day over the last several months. He drinks alcohol on a daily basis. He smokes a mild amount of marijuana.

He is on multiple medications including Pletal 10 mg once or twice a day for headaches, hydrocodone for pain, diazepam, Bextra 20 mg in the morning and 10 mg in the evening as well as Lexapro 10 mg a day for depression. He takes Protonix 40 mg once a day. He also takes ibuprofen 400 mg three times a day as well as multivitamins and calcium.

The general exam revealed a very slender male with a height of 6 feet 0 inches and a weight of 150 pounds. He states he has actually gained approximately 5 pounds recently. Examination of the head, eyes, ears, nose and throat revealed that he was not wearing glasses. His pupils were 3 mm bilaterally. His extraocular movements were full without nystagmus. He had no focal facial weakness. He had reasonable range of motion of his neck, although neck flexion caused some local discomfort. Neck extension was done reasonably well. He could flex his back to greater than 90degrees. Examination of the extremities revealed congenital defects of the right hand, especially the fourth and fifth digits, as well as the left thumb. He also had congenital defects of the right foot. There was bluish discoloration of his left fourth and fifth toes with very slight ulceration. I was able to palpate pulses in his feet (he does state he had some type of ultrasound studies of the vessels, and he reportedly has decreased blood flow to the legs). Again, he was able to flex his back to greater than 900 and had negative straight leg raising. He had reasonable movement of his shoulders. Neurologically, Mr. Cataldi was awake, alert and oriented. His higher cerebral functions including speech were intact. He had generalized weakness of the four extremities.

He had definite increased weakness of the distal upper extremities compared to the proximal. He was not able to dorsiflex his right foot and stated this has been that way "forever." His reflexes were brisk in the four extremities with the biceps jerk being 3 and the triceps jerk being 0 to I bilaterally. I did not appreciate any Hoffmann's bilaterally. He had sustained ankle clonus on the right and unsustained on the left. His Babinski's test was equivocal bilaterally. His position sense was intact in both lower extremities. His gait was mildly unsteady, and he had definite difficulties with tandem gait. His Romberg's testing was probably negative. He had a very mild decrease in finger-to-nose testing.

Mr. Cataldi certainly has a complicated picture. He appears to have cervical myelopathy and does have the above-noted stenosis at C3-C4, mainly being posteriorly. He does have changes of the cervical spine which probably is a combination of cervical spondylogenic changes. Some of the changes may be of a congenital nature however. He has nothing in the thoracic spine to explain his symptoms.

I would like to obtain routine cervical spine x-rays including flexion and extension views as well as a follow-up MR scan to this time include axial views through the cervical spine. For complete evaluation, would also like to have an MR scan without contrast done of the lumbosacral spine as well as an MR scan with and without contrast to be done of his head. I will see Mr. Cataldi back subsequently and discuss the potential treatment options.

Thank you for allowing me to participate in his care.

Sincerely,

Jack H. Deckard, M.D.
JHD/midwest DD: 06/16/03 DT: 06/18/03

cc: Robert Wetzler, M.D.

Addepdum: The patient did have extensive records of his past history in computer form. The total length of this consultation including review of the various records was 1 hour and 30 minutes.

January 31, 2003

MARVIN R. WOOTEN, M.D., A.C.P., S.C.
2025 EAST NEWPORT AVENUE, SUITE #210
MILWAUKEE, WI 53211
(414) 961‑1700

June 26, 2002

William Dicus, M.D.
625 East St. Paul Avenue
Milwaukee, WI 53202

RE: Vincent Cataldi

Dear Dr. Dicus:

I had the pleasure of seeing Vincent Cataldi in the office today regarding his complaints of tingling paresthesias in the hands and feet and paresthetic symptoms in the left torso. His history spans at least a year and possibly two. It is not clear that the history is progressive although the symptoms are of migratory and have been persistent over time to varying degrees. My overall impression is that he is suffering from a myelopathy at the T3 level. The etiology is indeterminate. The behavior of the condition has been relatively benign over the two‑year history, but he certainly has significant clinical defects on examination. The etiology is in apparent but possibly related to some congenital spinal pathology as the patient clearly has other congenital defects that are apparent. The only problem I have with his clinical localization is that it fails to provide any explanation for the patient's upper extremity symptoms. He also has some other minor findings on examination, including mild cerebellar incoordination in the upper extremities, that might suggest a more rostral lesion in the neck or even intracranially. While I cannot offer any firm hypothesis regarding the exact cause of the symptoms, it is clear that he has a central nervous system defect and, based on his history, that it is probably progressive. Imaging with magnetic resonance scanning of the thoracic spine and probably even the brain and cervical cord will be necessary. Because of the benign nature of his history, I do not believe the evaluation is emergent, and the patient is going to attempt to obtain some type of insurance coverage before embarking on this investigation. He will call me immediately if any progressive symptoms are noted. Otherwise he will call when he has some type of coverage that will allow this evaluation to proceed.

Sincerely,

Marvin R. Wooten, M.D., A.C.P. MRW/cjl 11451W