Anterior Discectomy and Fusion Using Simmons Keystone Technique: Case Reports

S.O. is a 35 y.o. principal ballet dancer and mother of two, she has always been extremely athletic and has continued on with her ballet career. About 5 years ago she noted aching in her neck and shoulder which she attributed to the usual aches and pains that most ballet dancers have in the course of their professional careers. In January of 1991 the neck ache increased and she consulted her physician who prescribed Vicodin for the pain. She went on vacation to Costa Rica and developed severe aching in her arm and numbness in her middle finger after a bumpy jeep ride. She returned to San Francisco and noted some weakness in her arm. The pain intensified to the point that she would have to get up at 2:00 a.m. and walk around her house. She tried a course of physical therapy, and chiropractic manipulation to no avail. She noted radiating pain in the back of the arm which radiated to the elbow and the dorsum of the wrist and hand when extending her neck. Wearing a soft collar and home cervical traction both eased the pain somewhat.

Examination: There was tenderness at C6-7 on deep palpation of the interspinous ligament. Flexion of the neck is slightly limited and extension produces tingling in the middle finger of the right hand. The cervical compression test intensifies the pain and distraction relieves it slightly. There is slightly diminished sensation to pin prick in the right middle finger when compared to the left The right triceps strength is rated 4/5 when compared to the left and there is an absent triceps reflex. The rest of the neurologic examination is normal including Babinski and Hoffman signs.

(fig. 6) MRI axial view of C6-7 disc showing displacement
of the C-7 root by large extruded disc fragment (small arrowhead),
resulting in weakness of the triceps muscle, loss of the triceps reflex,
and numbness of the middle finger. Note flattening of the spinal cord
(large arrowhead).

PM is a 53 y.o. dispatcher for a transportation company who slipped on the floor at work 7 years ago landing on her right shoulder. She was seen initially complaining of shoulder and neck pain and had an arthrogram of the shoulder which was interpreted as normal. She was evaluated by an industrial evaluation group who concluded that she was not seriously injured nor did she have a compensable injury. The pain persisted and a local orthopedic surgeon suggested that she have the shoulder arthroscoped. Currently she complains of neck pain, radiating to the trapezius and medial border of the right shoulder blade. She complains of no arm weakness but does complain of numbness in the ulnar two digits of the right upper extremity. Standing and sitting for 45 minutes aggravates the condition as well as flexing and rotating her neck. The pain is worse at the end of the day and awakens her every 4 hours from sleep. Rest decreases the pain and she also notices severe headache associated with the neck pain. The pain has progressed to the point that she can no longer work, and has taken Ascriptin, Advil, and Orudis to no avail.
Examination: Tenderness at both C5-6 and C6-7 levels to deep palpation. She can touch her chin within 4 cm of her chest and has diminished extension and rotation. The cervical compression test causes pain in the neck and shoulder only. There is normal painless internal, and external rotation of the right shoulder in full abduction. The sensory, motor, and deep tendon reflexes in the upper extremities are perfectly normal.

(fig. 9) Axial MRI of C5-6 disc showing protrusion
of the disc (small arrowhead), osteophyte formation,
and narrowing of the root canal by unco-vertebral joint
hypertrophy (large arrowhead). Bone appears black
on MRI.