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Cervical Disc Herniation Adjacent to Fusion

History

The patient is a 26-year-old healthy, nonsmoker, non-laborer. He is one-year status post C5-C6 anterior cervical discectomy and fusion (ACDF) and has done well during that time. He now presents with new acute onset of left shoulder pain and deltoid weakness. His neck and shoulder pain is significant.

Examination

There is no pain below the elbow. Deltoid weakness is 4+/5. There are no symptoms of myelopathy.

Prior Treatment

One-year ago he was treated for a right C6 radiculopathy (C5-C6 herniated nucleus pulposus) with anterior cervical discectomy and fusion (ACDF).

Images

Lateral and posterior anterior radiographs of the cervical spine demonstrate adequate alignment (Figs. 1A, 1B).

Lateral cervical x-ray; previous C5-C6 ACDFFigure 1A

Posterior anterior cervical x-ray; previous C5-C6 ACDFFigure 1B

Sagittal and axial MRIs demonstrate left C4-C5 disc herniation adjacent to fusion (Figs. 2A, 2B).

Sagittal and axial MRIs; C4-C5 disc herniation adjacent to fusionFigures 2A-2B

Diagnosis

C4-C5 herniation with C5 radiculopathy adjacent to prior fusion

Suggest Treatment

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Selected Treatment

The patient underwent plate removal through a contralateral exposure (vocal cords were normal bilaterally), fusion exploration, and junctional disc replacement after discectomy.

Postoperative cervical lateral and posterior anterior x-rays; disc replacementFigure 3A, 3B. Postoperative lateral and posterior anterior x-rays

Outcome

Treatment provided complete relief of radiculopathy and all neck pain complaints at 6-month follow-up.

This 26-year-old man underwent C5-C6 ACDF about a year ago with good outcome but has since developed new symptoms. His complaint, neurologic examination and MRI clearly point to C4-C5 herniated disc as being the culprit.

Prior to the advent of total disc arthroplasty, most surgeons would opt for anterior decompression and fusion for this patient. This still is the "tried and true" method to address symptomatic cervical disc herniation. To avoid fusing another level, posterior cervical discectomy may also be considered but is less than ideal for this patient since he had an adjacent level fused.

With three cervical disc prostheses currently FDA-approved, and more expected to follow, spine surgeons have another option. This technology, however, must be applied judiciously especially since we have limited long-term follow-up data. In older patients with osteoporotic bone or significant facet arthropathy, the fusion may still be the better choice. However, with one estimate that about 25% of the patients after ACDF will develop symptomatic adjacent segment disease within ten years, a total disc arthroplasty must be considered for younger patients.

Another factor to consider is the type of prosthesis to be utilized. This patient already had fusion and the supra-adjacent segment will be under greater stress especially with increased translation. Thus, choosing the implant designed to minimize the possibility of migration immediately after surgery is important. Even without previous fusion, prosthetic disc migration has emerged to be a problem for some cervical disc prosthesis currently under evaluation.

I believe that Dr. Albert provided this patient with the best available surgical treatment with the appropriate disc prosthesis. The only minor difference with his approach is that I would use the same surgical scar as the initial surgery rather than making a new incision.

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