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Gait and Balance Difficulties in a 76-Year-old Male

Patient History

The patient is a 76-year-old male who uses a wheelchair due to difficulties with gait and balance.

Examination

The patient's gait is broad-based and unsteady; he cannot tandem walk. Muscle testing revealed 3/5 left and 0/5 right extensor hallucis longus, and 0/5 right Achilles tendon. Knee reflexes at 3+, all others are zero. His Babinski response and Hoffman's sign were negative.

He has a history of a left craniectomy for meningioma.

Images

MRI shows severe stenosis at C3-C4, C4-C5 and C5-C6 secondary to degenerative subluxation of C4 with spondylosis. There is a kyphotic deformity at C4.

Sagittal MRI, severe cervical stenosis
Figure 1

Axial MRI, severe cervical stenosis
Figure 2A. C4-C5

Axial MRI, severe cervical stenosis
Figure 2B. C5-C6

Diagnosis

Degenerative spondylosis with stenosis C4-C6.

Suggest Treatment

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Selected Treatment

A C4-C6 corpectomy with fibular strut allograft was performed. Anterior fixation was then performed from C3 to C7 using a translational plate.

Postoperative PA x-ray, instrumentation from C3-C7
Figure 3. Postoperative PA x-ray shows instrumentation from C3 to C7.

Postoperative lateral x-ray, fibular strut graft in place of C4-C6 corpectomy with plate from C3-C7
Figure 4. Postoperative lateral x-ray shows fibular strut graft in place of C4-C6 corpectomy with plate from C3-C7.

Outcome

The patient's strength improved to near normal, but minimal improvement in balance. The patient continued to have difficulty with ambulation.

Case Discussion

This elderly gentleman has a gait disturbance that is probably related to spinal cord compression at the cervical level. His hands seemed to be spared and therefore it would be important to evaluate both the thoracic and lumbar regions with MR. This would rule out thoracic spinal cord pathology, or multiple lumbar nerve root compressions, both of which could account for his symptoms.

Although exceedingly rare, a metastatic meningioma could also be detected with MR imaging. Flexion/extension lateral cervical radiographs should also be obtained. If these studies do not add any significant new information, I would favor performing multilevel discectomies at C3-C4, C4-C5, and C5-C6.

There appears to be cerebral spinal fluid behind the vertebral bodies and review of the postoperative lateral radiographs indicates the facets are not fused. A 3-level discectomy approach would adequately decompress the spinal cord, enable proper sagittal realignment, and provide the opportunity to secure the spine with a pair of bicortical screws in each of the affected vertebrae.

If the patient did not completely improve within an appropriate time following surgery, a repeat MR scan should be performed. If there is any significant remaining spinal cord compromise, it should be addressed with a posterior decompression.

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