Radicular Neck Pain
The patient is a youthful 60-year-old female who presents with a history of neck pain, hand numbness, radiculopathy, dropping things, and hyper-reflexia.
There is no motor loss or weakness. She has lower extremity hyper-reflexia and bilateral Hoffman's sign.
Figure 1. Maximum extension
Figure 2. Post myelogram CT scan
Figures 3A and 3B
Cervical spondylotic myelopathy with severe neck pain and loss of lordosis
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Anterior intersegmental correction, with anterior cervical discectomy and fusion, followed by C3-T1 fusion, with instrumentation after laminectomy - C3, C4, C5 lateral mass screws with C7 and T1 pedicle screws.
Lateral postoperative x-rays. (Figs. 4A, 4B)
At six-months, one-year, and now at the two-year follow up, her neck pain has resolved along with all myelopathy signs and symptoms (resolution of hyper-reflexia, Hoffman's). She has full strength and normal motor function. She did have short-term swallowing issues, which mostly resolved to residual difficulty with certain foods. She is very satisfied with the treatment.
This case illustrates a patient with cervical myeloradiculopathy and neck pain who underwent multilevel decompression and fusion by a combined anterior and posterior approach. The clinical symptoms of hand numbness and dexterity problem (myelopathic hand syndrome), gait disturbance (imbalance) and exam findings of hyper-reflexia and Hoffman's signs are classic for cervical spondylotic myelopathy (CSM).
Imaging studies usually include plain radiographs including flexion / extension views, MRI and occasionally CT for assessing osteophytes. It is not necessary to obtain myelogram / CT scan in the majority of patients with CSM.
It is also important to assess associated symptoms of radiculopathy and neck pain. Radiculopathy could be due to disc herniations but, more commonly, foraminal stenosis, which is best evaluated by CT scans with 45-degree oblique reconstructions. If foraminal stenosis is present and symptomatic, decompression of the foramina should be performed in addition to decompressing the central spinal canal.
Many patients with CSM have concomitant C3 or C4 radiculopathy, which presents as a severe "neck pain." In addition to neck pain over the posterior trapezius muscles, some patients with C3 or C4 radiculopathy may have decreased sensation over the C3-C4 dermatomes. Foraminal decompression of these upper cervical roots is important to relieve the symptoms of "neck pain." Neck pain is more commonly associated with other conditions such as spondylosis, kyphosis, myofascial pain, etcetera.
In general, CSM patients with severe neck pain may have persistent or worsening neck pain following posterior laminoplasty and fusion is preferred in these patients. Posterior laminoplasty is an excellent procedure for patients with CSM with radiculopathy with minimal neck pain as long as the cervical lordosis is preserved. This patient had loss of lordosis but was not kyphotic. Some surgeons do advocate posterior laminoplasty or posterior laminectomy plus fusion, particularly if the cord compression is involved in more than 3 levels.
In patients with frank cervical kyphosis, posterior laminoplasty or laminectomy plus fusion should be avoided. Anterior discectomy, corpectomy, or a combination of corpectomy and discectomy is indicated in patients with cervical kyphosis and probably preferred if the spinal cord compression is involved at 3 or less motion segments with or without loss of cervical lordosis. In the majority of patients, either anterior decompression and fusion or a posterior procedure is sufficient to relieve the symptoms of myeloradiculopathy, but some patients may require a combined anterior and posterior procedure. One obvious example is a patient with severe fixed kyphosis requiring multilevel corpectomy. In this patient, posterior segmental fixation is preferred over anterior plating for a better biomechanically-sound construct.
This case example is similar to the patient just mentioned, although the kyphosis was not severe. I believe the combination of loss of lordosis, severe neck pain, and multilevel involvement is probably the reason for both an anterior and posterior approach. The surgeon appropriately chose discectomy instead of corpectomy as the cord compression is at the disc margins rather at retrovertebral region. Long fusion and instrumentation from C3 to T1 is also commendable as short fusion for kyphosis frequently leads to junctional problems.
The postoperative radiographs look excellent with some restoration of cervical lordosis and the resolution of her symptoms of myeloradiculopathy and neck pain is noteworthy. Many patients in the relatively early stage of myelopathy improve significantly, but if myelopathy is too severe, minimal or no improvement is expected following surgery.
This case brings many good teaching points on the treatment of patients with CSM. The surgery performed is not "usual and customary" for CSM; it was well-performed with excellent outcome.