Cervical Spondylotic Myelopathy with Cord Compression

History
A 65-year-old right-hand dominant lady presented with an 8-month history of left suboccipital and occipito-parietal pain and upper neck pain. Her pain was exacerbated by any head movements and radiated along the left arm. It was associated with numbness and paresthesias in the left hand fingers that waken her at night. She also complained of bilateral leg weakness; the left leg was weaker and gait imbalance.

The patient's past medical history includes type 2 diabetes mellitus and asthma. She sustained a whiplash injury 13-years ago after a road-traffic injury. She was pain-free for more than 7-years before her recent presentation. No history of rheumatoid arthritis.

Examination
On physical examination, this lady had a slightly limited cervical range of motion due to pain. She had some weakness in her left arm (4/5). Hyperreflexic left biceps reflex. Hoffmann's sign was absent bilaterally and her left toes had an extensor response on testing Babinski's reflex.

Blood Tests
Microcytic anemia. Elevated inflammatory markers (ESR and C-reactive protein). Negative rheumatoid factor and negative anti-nuclear antibody test. Negative TB skin test.

Radiological Findings
Radiographic investigation of the cervical spine included the following:

A lateral view demonstrated widespread spondylosis and narrowing of the spinal canal at multiple levels.

A computed tomography (CT) scan showed a soft tissue mass effect at the level of C1-C2 along the posterior aspect of the odontoid process with significant compression of the dural sac and spinal cord posterior and towards the right side. Minimal erosive changes are noted to involve the bony structure. Degenerative changes were noted at the mid and lower cervical levels and involve mostly the facet joints but, also the disc spaces. Foramina encroachment were noted at the C3-C4 level on the right side and again at the C4-C5 level on the right side. Anterior osteophyte formation in multiple levels.

Figure 1A

Figure 1B

Figure 1A-B. CT scans. Preoperative, sagittal reconstruction view, showing mass at the level of C1-C2 along the posterior aspect of the odontoid process with significant cord compression. Degenerative changes are noted at multiple levels.