Mixed Radiculopathy and Cervical Myelopathy
This patient is an attorney in her mid-50s. She has increasing amounts of axial pain, radiating pain in her right arm that extends to the dorsal of her hand, and numbness in her hand. However, her main complaint is neck pain. She has done her research on the treatment options available to her. She is not a smoker.
On examination, the patient has clumsiness in her hands.
The patient has tried several non-operative treatments, but nothing has worked.
Figure 1: Lateral flexion (left) and extension (right) x-rays; note the loss of disc space between C3-C4 and C4-C5.
Figure 2: Sagittal T2-weighted MRI
Figure 3: MRIs
Figure 4: Axial MRIs of C2-C3 (left) and C3-C4 (right)
Figure 5: Axial MRIs of C4-C5 (left) and C5-C6 (right)
Figure 6: Axial MRIs of C6-C7 (left) and C7-T1 (right)
Figure 7: Sagittal CT scans
Figure 8: Axial CT scans of C3-C4
Figure 9: Axial CT scans of C4-C5
Figure 10: Axial CT scans of C5-C6
Figure 11: Axial CT scans of C6-C7 and C7-T1
The patient was diagnosed with foraminal stenosis and facet arthritis leading to significant radiculopathy and cervical myelopathy.
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The patient underwent anterior decompression and fusion: disc level decompressions at C3-C4, C4-C5, and C5-C6 with instrumentation. Bone graft was also used.
Figure 12: Post-operative x-ray showing anterior decompression and fusion with instrumentation
The patient is doing much better neurologically.
This case provides an excellent basis for discussion of a common combination of painful and neurological complaints, as managed by a noted cervical spine expert. Though the patient's neurological symptoms serve as a stronger surgical indication, since they represent a greater threat to upper extremity function, her chief complaint of axial cervical neck pain will require careful "expectation management" in order to maximize patient satisfaction. Even a professional who has "done her research" needs to be told up front that the relief of axial symptoms following spine surgery can be unpredictable, and is in no way assured. Furthermore, it bears mentioning that the risk of requiring future interventions is significant.
The imaging studies demonstrate multiple areas of cervical facet arthrosis, perhaps most severely at C3-C4 on the left. Personally, I will routinely inspect the sagittal STIR images (not provided) for increased signal intensity in the subchondral bone of the facet joints, as it will often correlate with severe neck pain, which is typically ipsilateral to the area of reactive, inflammatory changes. And in cases without neurological concerns, I have successfully managed these patients with some combination of NSAIDs, traction, collar immobilization, and fluoroscopically guided intra-articular steroid facet injections. Thus far, I have never needed to operate in this setting. I should also mention that this step of examining the lateral masses for signal changes has yielded more than one diagnosis of metastatic cancer.
The facet arthrosis also correlates with the small degenerative spondylolisthesis at C3-C4 and C4-C5, which reduces nearly entirely in extension. In general, I do not believe that this "instability" is nearly as significant in the cervical spine, as it can be in cases of lumbar spondylolisthesis. However, I do believe that spinal cord compression in combination with abnormal facet motion leads to more severe cases of myelopathy than comparable spinal cord compression alone, and in that setting, fusion is typically required for definitive neuroprotection. The presence of increased cord signal intensity at C3-C4 is clearly a result of this combined compression and instability.
So the selection of an anterior cervical arthrodesis is an excellent choice since it will allow for rapid recovery and return to work for an office-based professional. However, if this attorney is a litigator who spends significant time addressing juries in the courtroom, she must be apprised of the small risk of dysphonia, be it temporary or permanent. In our practice, the pre-operative checklist includes asking patients whether their professional or recreational activities involve singing or public speaking, such that an anterior procedure could possibly jeopardize their voice, so as to allow patients to choose their preferred approach based on their risk tolerance.
I would take care to point out the presence of large posteriorly based facet osteophytes contributing to the foraminal stenosis in multiple neuroforamina, in conjunction with the typical uncovertebral osteophytes. In general, but as a rule in this setting, I favor an aggressive uncovertebral resection, with removal of the entire uncinate process out to the lateral border of the caudal pedicle. Because the facet osteophytes will not be removed during the anterior procedure, a very thorough foraminal decompression is required in order to minimize the risk of persistent nerve root compression and the possibility of needing a posterior microlaminoforaminotomy if radicular symptoms persist.
However, one reason I would favor an anterior approach here is the strong likelihood of transition syndrome. The sagittal T2 image shows that the C6-C7 disc is already protruding, and the right C7-T1 neuroforamen is quite tight from unilateral collapse and facet osteophytes. And given the patient's likely genetic predisposition to both disc and facet degenerative changes, her fusion will probably need to be extended to T1 during her lifetime. Given the difficulty of achieving solid fusion below a long arthrodesis, coupled with the likely need to cross the cervicothoracic junction, I would approach her eventual surgery for transition syndrome circumferentially. And in my practice, I try to limit patients to a single posterior cervical procedure per lifetime, given the added pain and recovery involved.
Finally, I would like to comment on the technical excellence shown on the post-operative radiographs. The appropriately-sized allografts provide enough distraction to decompress the neuroforamina without stretching the facets excessively to cause post-operative pain. As one would expect, the spondylolisthesis has reduced with distraction, but that is not critical to clinical success. Lordosis has been restored to physiologic alignment. There is very nice graft-to-end plate apposition for maximal bone contact for healing, and the subchondral bone has been decorticated enough so that it is barely visible on the lateral radiograph, balancing structural support with exposure to cancellous healing surfaces. The plate is placed perfectly, such that it does not come too close to the supra- and subjacent discs, which would risk adjacent level ossification. Still, the bottom screws are placed low enough within the C6 vertebral body such that they act as true unicortical screws, with a solid rim of cortical purchase to resist toggling or settling forces at the area most prone to implant loosening. And the screws are nice and long to maximize bony purchase without intruding the spinal canal. I would consider this construct to be technically perfect.