Author: Bridget Doyle, DO, MPH
Co Author #1: Kyle Geissler, MD
Co Author #2: Lauren Splittgerber, MD
Senior Editor: Carolyn Landsberg, MD
Editor: Jason Blackham, MD

Patient Presentation:
A 46-year-old female physician was on vacation partaking in surface-supplied diving when she lost her oxygen supply due to equipment failure. She was about 60 feet below sea level and ascended more rapidly than planned. Once the patient reached the surface, she felt sudden, sharp, right-sided neck pain.

History:
The patient consulted her Sports Medicine colleague one week later for on-going right sided neck pain. At that time, her neck pain was 2/10 pain severity and worse with movement. She denied swelling, redness, numbness/tingling, shooting pain, headache, vision changes, upper extremity or lower extremity weakness, or any gait abnormality. Her physical exam was unremarkable except for mild tenderness to palpation of her right cervical paraspinal muscles. Her Sports Medicine colleague diagnosed her with a benign right cervical strain caused by awkward positioning during rapid ascension. She was instructed on a home rehabilitation program and was advised to take Tylenol and Ibuprofen as needed for pain.

She presented to a Family Medicine clinic two weeks later due to the development of new symptoms. At that time, she reported the pain now radiated up her neck towards her right ear. She also experienced transient episodes of right-sided facial and arm numbness with associated dysarthria, racing heart, palpitations, shortness of breath, diaphoresis, and feelings of impending doom lasting about 2-3 minutes at a time. These symptoms resolved with breathing exercises. It progressed to include ataxic gait and blurry vision lasting about 2-3 hours at a time.

An MRI brain was ordered and obtained two days later which was unremarkable. Five days later (now four weeks after the scuba incident), the patient developed acute worsening of her right-sided neck pain, facial numbness, headache, ataxia, and blurry vision lasting 3 hours and she presented to the hospital.

Physical Exam:
She was alert and oriented x4 with mild distress. Her heart exam showed regular rate and rhythm with normal S1/S2 and no murmurs. Her lungs were clear to auscultation bilaterally with non-labored respirations. She had full active and passive range of motion of cervical spine with mild pain with flexion, extension, and right side-bending, and no swelling or erythema of cervical spine but mild tenderness to palpation of right trapezius and right splenius capitis muscles. Her neurologic exam showed fluent speech, comprehension intact and no dysarthria with extra ocular movements intact. Cranial nerve exam was remarkable for gaze evoked nystagmus (Right greater than Left), facial sensation reduced to light touch and temperature in right V3 distribution. There was no facial asymmetry, hearing grossly intact and tongue was midline. Sensation was intact bilateral upper extremities and lower extremities with 5/5 strength.
Reflexes were 2+ bilateral upper extremities and lower extremities.
She had ataxia and leaning to the right with walking, dysmetria of right upper extremity and bilateral lower extremities but negative pronator drift, and negative Romberg.

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