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Multi-level Cervical Fusion with Significant Risk of Pseudarthrosis

Progressive Worsening Neck Pain and Radiculopathy

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History

A 52-year-old female smoker presents with progressive worsening of her neck pain and radiculopathy that is affecting her work as a chief financial officer. She has worsening arm numbness and tingling with increasing weakness that limits her computer work time and participation in leisure activities. She has had to suspend aerobic exercise activities due to the exacerbating effects on her neck pain.

Examination

The patient stands with her neck flexed slightly forward. She has difficulty with extension past neutral and flexion is painful. Lateral rotation of 50-degrees in either direction is possible before the onset of pain and shooting pain into the upper extremities.

  • Right elbow extension weakness
  • Left wrist extension weakness
  • Decreased bilateral sensation in the C6, C7 and C8 dermatomes
  • Bilaterally positive Spurling's sign 
  • Positive Hoffman's sign
  • Depressed deep tendon reflexes

Prior Treatment

The patient had several months of physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxant and non-narcotic pain medication. These treatments briefly helped. Overall, the effects were short-lived and unsatisfactory.

Pre-treatment Images


cervical lateral x-ray, pre-treatment
Figure 1. Lateral x-ray

cervical sagittal MRI, pre-treatment
Figure 2. Sagittal MRI

Diagnosis

Multi-level C3-C7 cervical spondylosis, cervical stenosis, herniated nucleus pulposus and nerve root impingement bilaterally.

Suggest Treatment

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Selected Treatment

Although it is always my practice to do as little as necessary, I felt we could not ignore any of the significant and bilateral herniated discs causing bilateral symptoms and central stenosis at every level. Together with the patient, we selected a combined anterior-posterior approach. Although this choice meant more surgery than an isolated anterior-only or posterior-only approach, the combined approach provided greater fixation and decreased the possibility of a pseudarthrosis.

A Cervical-Stim® Bone Growth Stimulator was chosen for this patient's use during the post-operative course of her care. Pseudarthrosis would mean returning to the operating room and greater disruption of her professional life. Involvement of the bone growth stimulator early was an essential and provided every modality available to minimize the risk of pseudarthrosis in this high-risk patient.

Post-operative Images

multilevel post-operative cervical, lateral x-ray
Figure 3. Immediately post-operative

multilevel 4 months post-operative cervical, lateral x-ray
Figure 4. Four months post-operative

Post-operative Course
The patient's post-operative course was uncomplicated. Her upper extremity neurological symptoms immediately resolved. Weakness soon resolved. Wounds healed without event. Posture improved.

She returned to work—from home, within one week. One month after surgery, she started commuting back to work partial days combined with work from home. By two months after surgery, she returned to a full work schedule. The patient was never braced post-operatively.

Throughout the post-operative care, she was highly compliant in use of the bone growth stimulator. Her use was monitored utilizing its computerized monitoring/reporting capability.

Outcome

  • The patient returned to a full work schedule without medications by three months.
  • The bone growth stimulator was discontinued 6 months after surgery.
  • Radiographs demonstrated instrumentation in place with evidence of bony ingrowth.
  • She had no activity restrictions.

Surgeon's Treatment Rationale

Multiple factors can influence spinal fusion, including multilevel surgery,1 tobacco use,2 NSAID use,3 metabolic factors (e.g., endocrine disease, bone quality, malnutrition, vitamin deficiencies), and rheumatologic disease.4 This patient presented with multiple risk factors, including Vitamin D deficiency, tobacco habit, NSAID use, and a multi-level surgical procedure. Given the high risks of pseudarthrosis, lengthy recovery and/or possible revision, Cervical-Stim with Pulsed Electromagnetic Field (PEMF) was warranted.

Furthermore, the standard of care can be regional and many patients in the Northeast are aware of this technology and request information about it.5,6 In my practice, PEMF bone growth stimulation is an essential part of the care all spinal fusion patients receive.

References:

  1. Shen H, Buchowski J, Yeom J et al Pseudarthrosis in multilevel anterior cervical fusion with rhBMP-2 and allograft. Spine. 2010 Apr;35(7):747-753.
  2. Hilibrand A, Fye M, Emery S et al. Impact of smoking on the outcome of anterior cervical arthrodesis with interbody or strut grafting. JBJS Am. 2001 May;83-A(5):668-73.
  3. Gebremariam L, Koes BW, Peul WC, Huisstede BM. Evaluation of treatment effectiveness for the herniated cervical disc: a systematic review. Spine. 2012 Jan 15;37(2):E109-18.
  4. Grob D, Luca A, Mannion AF. An observational study of patient-rated outcome after atlantoaxial fusion in patients with rheumatoid arthritis and osteoarthritis. Clin Orthop Relat Res. 2011 Mar;469(3):702-7.
  5. Foley KT et al. Randomized, prospective, and controlled clinical trial of pulsed electromagnetic field stimulation for cervical fusion. Spine J. 2008 May-Jun;8(3):436-42.
  6. Mackenzie D, Veninga FD. Reversal of delayed union of anterior cervical fusion treated with pulsed electromagnetic field stimulation: case report. South Med J. 2004 May;97(5):519-24.

Indications
The Cervical-Stim® is a noninvasive, pulsed electromagnet bone growth stimulator indicated as an adjunct to cervical fusion surgery in patients at high risk for nonfusion.

Physician's Disclosure
Alexios Apazidis, MD, MBA received remuneration for his case presentation.

Case Discussion

Dr. Alexios Apazidis is commended for the excellent clinical and radiographic results he obtained during the treatment of this difficult problem. The patient presents axial neck pain with cervical radiculitis manifested as decreased sensation in the C6, C7 and C8 distributions and weakness in her wrist extension and elbow extension. Fortunately, she does not have overt myelopathy (long tract signs), but was found to have a positive Hoffmann's signs. The Hoffman sign is not a very specific finding and can be seen in the absence of spinal cord compression, particularly in younger females. The patient had no other long tract signs (i.e., hyper-reflexia, Babinski sign, tandem gait difficulty), but in fact, had decreased tendon reflexes most likely due to her radiculopathies. The patient attempted conservative algorithm treatment for her spinal disorder, including: physical therapy, NSAIDs, and non-narcotic pain medications. These therapies were unfortunately not particularly beneficial.

Pre-treatment images illustrate a well-maintained cervical lordosis on her upright lateral x-rays. Unfortunately, we do not have full access to all the pre-operative images, but the cervical MRI illustrates she has multiple levels of spondylosis, particularly at C3-C4 and C4-C5. However, she clinically appears most symptomatic at C5-C6 and C6-C7 levels.

In this particular patient, the diffuse spondylosis and axial neck pain make the identification of her primary pain generator difficult. The isolation of the exact etiology of the patient's symptomology is necessary in order to maximize the patient's outcome. One option, to aid in the identification of which particular nerve roots are severely symptomatic, is the use of epidural steroid injections, selective nerve block or even the possibility of pre-operative EMGs. However, in this patient she appears to have all cervical levels affected.

I agree that the surgeon needs to decide the levels and goals of the surgical intervention prior to planning their surgical approach. In this case, if the approach was to treat her C5-C6 and C6-C7 regions and disease, then an isolated anterior approach would likely be ideal. However, this would not address her severe spondylosis proximally, which may be symptomatic. Due to the increased risk of surgical morbidities with a C3-C7 fusion, I would have been reluctant to proceed with a C3-C7 fusion in a patient without myelopathy.

However, if a C3-C7 fusion is planned, the surgeon can proceed from an anterior, posterior or combined approach. In a kyphotic patient, the anterior approach is helpful in correcting the deformity and aligning the spine. However, in a lordotic patient, a posterior approach and decompression is sufficient in decompressing the spinal cord.

The present patient is interesting in that her complaints are axial neck pain and radiculopathies without spinal compression. Axial neck pain may be related to her severe spondylosis, and thus a fusion may aid in eliminating the pain. However, results with a posterior decompression and fusion typically are not very good for neck pain due to the dissection of the posterior musculature. The author, therefore, decides to proceed with an anterior fusion C3-C7 with interbody grafts. The anterior grafts provide for indirect decompression of the nerve roots due to the distraction of the disc spaces.

However, with any anterior cervical fusion, there is a risk of pseudoarthrosis.1-4 The risk is increased when proceeding with greater than three levels, and tobacco use. I believe the greatest risk factor for her obtaining a pseudoarthrosis is not, however, the length of her fusion, but rather her tobacco usage. Therefore, in an elective procedure such as this, I would require her to stop tobacco use prior to her operative treatment. Unfortunately, however, in several of our patients, we do not have the luxury of an elective procedure such as a patient with a rapidly accelerating myelopathy. It is therefore, often helpful to use an external stimulation device in order to obtain a solid arthrodesis. These non-invasive, pulsed electromagnet bone growth stimulators are well received by the patients and have been illustrated significantly increasing the fusion rates.5 Unfortunately, pseudoarthrosis are manifested in a delayed manner, and although I concur, the four-month results are quite excellent, patients need to be followed for at least one year to truly document a solid arthrodesis.

References
1.Hilibrand AS, Dina TS. The use of diagnostic imaging to assess spinal arthrodesis. Orthop Clin North Am. 1998; 29: 591-601.
2.Martin GJ, Haid RW, MacMillan M, et al. Anterior cervical discectomy with freeze-dried fibula allograft: Overview of 317 cases and literature review. Spine. 1999; 24: 852-9.
3.Newman M. The outcome of pseudarthrosis after cervical anterior fusion. Spine. 1993; 18: 2380-2.
4.Phillips FM, Carlson G, Emery SE, et al. Anterior cervical pseudarthrosis: Natural history and treatment. Spine. 1997; 22: 1585-9.
5. Foley KT, Mroz TE, Arnold PM, et al. Randomized, prospective, and controlled clinical trial of pulsed electromagnetic field stimulation for cervical fusion. The Spine Journal. 2008 May-Jun;8(3):436-42.

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