Cervical Spondylosis with Myeloradiculopathy Multilevel Laminectomy, Foraminotomy, Fusion, and Lateral Mass Plating - Case History

CASE HISTORY

The patient is a 75 year–old black female who presented with a chronic, sharp, bilateral neck and right radiating shoulder pain and occasional right hand numbness. The patient's neck pain radiated from the base of the neck to the upper thoracic spine. Her symptoms had been mild for 3–4 years and recently the shoulder and neck pain had been excruciating for 5 months.

The patient also reported dizziness, a feeling of imbalance, difficulty sleeping, and posterior and frontal headaches. The patient reported no bowel or bladder dysfunction. Of further interest, the patient did not smoke, did not consume alcohol, was retired, and lived alone.

Past Medical History

Other medical ailments included hypertension, abdominal adhesions, arthritis, and osteoporosis. Her past surgical history was significant for a total abdominal hysterectomy, intestinal surgery, tonsillectomy, upper jaw bone removal, and an appendectomy.

Physical Examination

On physical examination, the patient displayed tenderness to palpation in the lower cervical region. Further evaluation demonstrated painful cervical extension at 25 degrees, flexion at 30 degrees, and bilateral rotation at 40 degrees. Neurologic examination showed slight sensory deficits at C5 and C6 distributions on the right and 4/5 motor strength of the right deltoids. Hoffman's sign was equivocal and the reflexes were 3+ throughout. Shoulder range of motion was found to be normal and the anterior aspect of the shoulder and the AC joint were tender.

Radiographs

Severe cervical degenerative changes were noted on radiographic evaluation. Plain radiographs revealed the presence of moderately advanced hypertrophic changes at C3–C6 with intervertebral disc space narrowing at C4–C5, C5–C6, and C6–C7 (Fig. 1: A, B). Bilateral neural foraminal encroachment with greater prominence on the left was also noted at the levels of C3–C7. MRI of the right shoulder indicated a partial tear of the supraspinatus muscle.

MRI of the cervical spine indicated a mild loss of lordosis accompanied with multilevel degenerative changes from C2–T1 causing effacement of the dorsal and ventral aspect of the thecal sac with mild cord compression (Fig. 2). A posterior disc bulge was present at C2–C3 with resultant central spinal stenosis in absence of significant foraminal stenosis. However, a posterior disc bulge and spur formation at the level of C3–C4 was noted in producing mild central spinal stenosis and right foraminal stenosis (Fig. 3). Furthermore, severe central spinal stenosis and bilateral foraminal stenosis were apparent and secondary to posterior disc bulges at C4–C5 and C5–C6. Moderate spinal stenosis and bilateral foraminal stenosis, as a manifestation of a posterior disc bulge and spur formation, was also noted at C6–C7.

CASE MANAGEMENT

The patient's complaints correlated with her diagnostic imaging studies. Multiple courses of physical therapy, oral medication, and epidural steroids were implemented, but did not provide successful symptomatic relief. Subsequently, degenerative changes with mild to severe central spinal and foraminal stenosis at the levels of C3–C7 and failed conservative treatment for four months led to operative intervention to relieve symptoms.

The patient underwent laminectomies at C3, C4, C5, and C6 with right–sided foraminotomies at C3–C4, C4–C5, and C5–C6. Posterior cervical lateral mass plate internal instrumentation with fusion from C3–C7 with autologous iliac crest bone graft was performed. The bone was osteoporotic, but screw purchase was deemed adequate. The blood loss was 250 cc. The patient was then placed in a Philadelphia collar for external immobilization and discharged in four days.

Due to the patient's medical history and multilevel surgical procedure, she is at a risk for non–union. In order to minimize such effects, the patient was instructed to wear an Orthofix external bone growth stimulator for 3 hours per day for 6 months. PEMF therapy was utilized to increase vascularization and encourage osteoblastic activity to the fusion site.