Age: 60.0
Sex: M
Vaccine: LYME
Symptoms: Arthritis, Arthropathy, Joint range of motion decreased, Laboratory test abnormal, Neck pain
Clinical narrative: Report A0359975A describes cervical facet arthritis in a 60 year old male who received Lyme disease vaccine recombinant OspA (LYMErix). This report was received as part of litigation proceedings, with forwarding of medical records. The medical history included allergy to paper, tuberculosis and scarlet fever as a child, perianal fistulas, hypertension, hypercholesterolemia, "mild" chronic obstructive pulmonary disease, benign prostatic hypertrophy, impotence (1997), prostatitis (1986), epididymitis (1995), ureteral stone (1995), gall bladder polyps, gastritis (1989), "mild" esophagogastric junctional inflammation, liver hemangiomas (1993), parapelvic bilateral kidney cysts (1993), low back pain (1990), upper neck pain (1995), "modest" right-sided conductive hearing loss (1994), vestibular neuronitis, two myocardial infarctions, palpitations, ischemic cardiomyopathy, right buncle branch block, arteriosclerotic heart disease (1996), angina, "mild" mitral regurgitation, "mild" tricuspid regurgitation, "mild" aortic regurgitation, drusen in macular both eyes, possible "recurrent erosion of the right eye" (1998), intraretinal hemorrhage right eye, Eustachian tube dysfunction (1996), and scattered subclinical lymphadenopathy (1997). The pt smoked two packs of cigarettes per day for 25 years but switched to cigars in approximately 1958. The surgical history included cholecystectomy, two anal fistulectomies, and percutaneous transluminal coronary angioplasty. Concurrent medications included Tylenol, Nasonex, Augmentin, sublingual and transdermal nitroglycerin, Lopressor, Flonase, Zocor, Zestril, enteric-coated aspirin, vitamin E, and selenium. On an unspecified date, the vaccinee received an injection of LYMErix; it was not known if he had received previous injections of LYMErix. In a Statement of Injuries, his attorney alleged that the vaccinee "experienced neck and shoulder pain including cervical facet arthropathy." Following the reported onset of neck and shoulder pain including cervical facet arthritis, the vaccinee experienced basal cell carcinoma, viral upper respiratory infection, acute sinusitis, diverticulitis, contact dermatitis, otitis media and elevated liver enzymes. These events were not reported as adverse events due to vaccine administration, but were found during the course of review of the vaccinee's medical records. Therefore, they are not listed as adverse events.  On 6/28/00, the pt was seen by the physician. He complained of right shoulder pain. The pt was taking Celebrex. On 6/29/00, x-rays of the cervical spine revealed abnormalities. On 7/7/0, the pt was seen by the physician. He was "still having problems with the neck into the right arm despite of Celebrex." MRI of the neck revealed abnormalities. The physician made an assessment of "cervical arthritis." On 7/25/00, the pt was evaluated by the neurosurgeon. He wrote "the pt has been experiencing neck pain for the past few years. This became more prominent in December 1999, and was not antedated by any trauma or unusual activity. He complains of neck pain with radiation to his right shoulder but no radiation to his arm. There are no complaints of paresthesias. he is a right-handed individual and has not experienced any power loss. The discomfort is intense at times and he is unable to sleep at night. He has been treated with physical therapy and exercises and is now taking Celebrex. On examination, he is a well develped gentleman in no acute distress. There is a full range of motion of his cervical spine in all directions but forced extension will exacerbate his symptoms. Neurologically I find no evidence of motor weakness, sensory deficit or reflex disymmetry. I did review an MRI scan of his cervial spine and see that there is stenosis with osteophytes at the C5-C6 level narrowing the midsaggital diameter to 8 millimeters. AT C3-C4, C4-C5, and C6-C7, the midsagittal diameter is about 9mm (10mm is low normal). It is my impression that this gentleman has cervical stenosis as well as cervical osteophytes causing cervical radiculitis. I have suggested that he may benefit from a course of cervical epidural steroids." On 8/8/00, the pt was seen by the physician at the pain control center. The pt presented "with chief complaints of pain in the neck right side more than the left, radiating to his right shoulder and right traperial area of 8-10 months duration. He also has occasional numbness in both arms, right somewhat more than the left, since 2-3 years ago. History of present illness: He has had the above-mentioned complaints on and off the past couple of years but in the last month his pain particularly in the right shoulder and right trapezial area has gotten worse. Essentially he has stopped playing tennis and various other activities that he likes to do because of it. Several months of physical therapy and various medications have not been effective. Pain medications: he takes Celebrex 200mg 1-2 pills a day with mild improvement of his condition. Multiple other nonsteroidal anti-inflammatory medications were very irritable to his stomach. Physical examination: reveals a pleasant 60 year old male, 162 pounds, 5 feet seven inches, in some distress due to the pain in the right neck radiating to his right shoulder  and righ ttraperial ara. He has diminished right biceps jerk with somewhat diminished right shoulder abduction. Cervical axial compression reporduced right C4-C5 radiculopathy. He has a diminished range of motion in the cervical spine with straightening of the cervical lordosis. he also has bilateral cervical paravertebral spasm and tenderness along the cervical facet joints on the right more than on the left. There are no complaints of bowel or bladder dysfunction. There are downgoing big toes on plantar stimulation and there is no ankle clonus. Studies: MRI of the cervical spine from July of this year revealed C3-C4 herniated disc to the right with multi level cervical spondylosis and mild to moderate cervical stenosis. X-ray findings were suggestive of C4-C5 and C5-C6 lateral foraminal stenosis right more than left. Impression: 1. Right C4 radiculopathy, secondary to herniating C3-C4 disc, poorly responsive to 8 months of physical therapy and various medication. 2. Multi level painful cervical facet arthropathy. 3. Degenerative cervial spine disease with mild to moderate multi level cervical stenosis from C3 down to T1 level. Suggestions: I explained to the pt all the pros and cons of his conditions, as well as refilling his Celebrex 200mg twice a day and starting him on Elavil 25mg at bedtime. We will proceed with cervical facet and if needed cervical epidural injections of medications over the next few weeks. Apparently it is a very serious problem and there is no simple solution for that." Right cervical facet joints at C2-3, C3-4, C4-5, C5-6, and C6-7 (five levels) were identified and injected with 5mg Aristocort mixed with 1cc 1% preservative-free lidocaine per segment. On 9/6/00, the pt was treated by the pain management physician. The pt reported some improvement of pain in the right neck and right upper shoulder after his treatment two months ago, but he was still symptomatic with significant amounts of pain, spasm, and tenderness along the cervical facet joints mostly on the right side at C2-3 through C6-7 level. He also had restricted range of motion in the cervical spine by 30-50%. Cervical axial compression maneuver reproduced right-sided mostly C4 and C5 radiculopathy. Five levels of right cervical facet joints were injected with 5mg triamcinolone mixed with 1cc 1% lidocaine per segment. The physician's impression was "multi level cervical facet arthropathy with mostly right sided cervical radiculopathy partially responsive to cervical facet joint injections of medications." On 11/1/02, the pt was treated by the pain management physician. The pt reported a gradual but definite improvement of pain in the right neck. He was about 50-60% better after two right cervical facet joint injections administered over the past several months. However, he was still symptomatic with residual painful and limited cervical range of motion and cervical extension as well as tenderness along the cervical facet joints mostly on the right side at C2-3 through C6 region, with the main focus at C3-4 and C4-5 region. "In view of his good response to intermittent perispinal injections while failure of multiple physiotherapeutic modalities over the years, he requests the same. I think it is a reasonable option to exercise." Five levels of cervical facet joints were injected with 5mg triamcinolone mixed with 1cc 1% lidocaine per segment. On 1/31/01, the pt was treated with the pain management physician. The pt reported definite improvement of pain in the right side of his neck as a result of his treatment in September and August of last year. According to him, his right neck and right upper extremity pain was at least 60% better at this point. However, his pain in the left side of the neck in cervical paravertebral area along the cervical facet joints still remained a problem with painful and limited cervical range of motion and left more than right cervical paravertebrral spasm and tenderness along the cervical facet joints at C2-3 through C6 level. Five levels of left cervical facet joints were injected with 5mg triamcinolone mixed with 1cc 1% lidocaineper segment. On 2/19/01, the pt was seen by the physician. "He still gets some occasional neck stiffness but it is definitely better. He has been taking Celebrex and glucosamine and also getting cervical injections of cortisone and that seems to be working." On 3/28/01, the vaccinee was treated by the pain management physician. He reported "significant" improvement in both upper extremities with essentialy no more numbness there as a result of his treatments over the past 6-8 months or so. Also, he reported significant improvement of pain in the left side of his cervical spine that was treated 2-3 months ago. However, his pain in the right cervical paravertebral region had increased, "apparrently due to significantly more humid and colder weather."Right cervical facet joints. He is still reluctant to undergo a major cervical decompression for severe spinal stenosis. Impression: Severe spinal stenosis and painful cervical facet arthropathy." On 7/11/01, the vaccinee was treated by the pain management physicin. He still reported "significant" improvement of pain in the right neck. His pain in the left neck was "doing very well over the past 6-7 months" however, on 7/11/01, there was increased pain in the left side of his cervical spine with decreased range of motion and somewhat painful and limited cervical extension and deflection, consistent with exacevation of his painful cervical facet arthropathy. Five levels were injected with 5mg triamcinolone with 1cc 1% lidocaine per segement. On 10/10/01 the vaccinee was treated by the pain management physician. Overall, the pt reported 50-70% improvement of pain in the neck since the physician started treating him one year ago. He was doing "very well" for about six months after intermittent perispinal cervical facet joint injections on each side, "which is excellent considering the nature of his condition and poor response after various pharmacological and physiotherapeutic modalities in the past." The pt presented with somewhat painful and limited cervical extension and deflection and mostly right-sided cervical paravertebral spasm and tenderness along the cervical facet joints at C2-3 throught C6-7 level consistent with exacerbation of painful cervical facet arthropathy on the right. Right cervidal facet joints at five levels were injected with 5mg triamcinolone mixed with 1cc 1% lidocaine per segment. On 1/9/02, the vaccinee was treated by the pain management physician. The pt still reported significant improvement of pain in the right neck after his last treatment in October. However, his pain in the left neck that the physician "had not addressed" over the past 7 months was getting worse, especially with colder weather. He presented with painful and limited cervical extension and deflection and mostly left-sided cervical paravertebral spasm and tenderness along the cervical facet joints, consistent with exacerbation of painful cervical facet arthropathy. Five levels of left cervical facet joints were injected with 5mg triamcinolone with 1cc 1% lidocaine per segment. On 4/10/02, the vaccinee was treated by the pain management physician. Overall, the pt reported 50-60% improvement of pain in the neck as a result of his treatments over the past several months. He was able to do much more at home and socially, and "he really enjoys it." However, he still had some residual neck pain. It had gotten somewhat worse, and on 4/10/02, he had painful and limited cervical extension and deflection, mostly right-sided cervical paravertebral spasm and tenderness along the cervical facet joints at C2-3 through C6-7 region, consistent with exacerbation of painful cervical facet arthropathy. Five levels of right cervical facet joints were injected with 5mg triamcinolone mixed with 1cc 1% lidocaine per segment. The most recent info received on 6/11/02, indicated that the neck pain persisted as of 4/10/02, but had improved.