SpineUniverse Case Study Library

Cervical Degenerative Disc Disease: 34-year-old Male

Patient History

The patient is a 34-year-old male with no significant past medical history. His complaint is mild neck pain, which developed 2 months ago after falling caused him to strike his chin and hyperextend his neck. He developed diffuse upper extremity paresthesias immediately upon impact that resolved over several hours. He did not seek immediate medical attention.

Besides mild neck pain, his current complaints are finger tip tingling, stable hand weakness and a loss of fine motor control, and left greater than right tingling along the posterior upper extremities. The patient denies any lower extremity involvement, gait instability, or bowel and bladder dysfunction.

Examination

The patient demonstrates normal range of motion. There is no pain or paresthesias with flexion or extension. He presents mild bilateral tricep weakness of 4+/5 and bilateral grasp weakness; left 4/5, right 4+/5. There is decreased left C7 sensation to pinprick. His reflexes are hyperactive with bilateral Hoffman's sign.

Images

The cervical x-rays show cervical lordosis, mild spondylotic disease at C5-C6 and C6-C7 (Figures 1,2), and no instability on flexion and extension view (Figures 3,4).

Cervical MRI studies show loss of cervical lordosis, degenerative disc disease from C3-C4 to C6-C7 (Figure 5), mild to moderate left hemicord compression at C5-C6 and C6-C7 (Figure 6), and left foraminal stenosis at C5-C6 and C6-C7 (Figure 7).

Cervical x-ray, lordosis, mild spondylotic disease, C5-C6, C6-C7
Figure 1

Cervical x-ray, lordosis, mild spondylotic disease, C5-C6, C6-C7
Figure 2

Cervical x-ray, lordosis, mild spondylotic disease, C5-C6, C6-C7, no instability
Figure 3

Cervical x-ray, lordosis, mild spondylotic disease, C5-C6, C6-C7, no instability
Figure 4

MRI, lordosis, degenerative disc disease, C4 to C6-C7
Figure 5

MRI, hemicord compression at C5-C6, C6-C7
Figure 6

MRI, left foraminal stenosis at C5-C6, C6-C7
Figure 7

Diagnosis

Cervical spondylotic myelopathy with associated left C7 radiculopathy.

Suggest Treatment

Indicate how you would treat this patient by completing the following brief survey. Your response will be added to our survey results below.

Selected Treatment

The patient underwent an anterior cervical discectomy and fusion at C5-C6 and C6-C7 with PEEK/BMP interbody grafting and anterior plate stabilization. There were no complications.

Post-operative posterior x-ray, 8 months
Figure 8

Post-operative lateral x-ray, 8 months
Figure 9

Post-operative lateral x-ray, 8 months
Figure 10

Post-operative lateral x-ray, 8 months
Figure 11

Outcome

At 8-months following surgery, the patient was doing very well. His neck pain was improved, upper extremity paresthesias resolved, improved hand paresthesias, no focus motor deficits, and solid fusion at C5-C6 and C6-C7.

Case Discussion

Doctor Kaiser presents a case of a patient with an acute traumatic incidence of neck pain followed by radiculopathy. My work-up, or plan, would be similar to what he has done in this case.

Besides taking a routine patient history, and because of the traumatic event, I'd obtain x-rays consisting of AP/lateral plus flexion-extension films. For patients without profound neurological involvement, I would immediately start analgesics with or without a Medrol dose pack and physical therapy followed by re-evaluation in 2-weeks.

The patient would be instructed to contact me if their arm pain and/or numbness increased. If there was no improvement at the 2-week follow-up visit, or the patient's radiculopathy worsened, an MRI would be ordered.

Assuming the patient failed to improve despite these non-operative treatments, and depending on MRI findings, epidural injections may be considered. In certain patients with mild to moderate MRI findings, I may try epidural injections.

In this particular patient, with C6-C7 nerve root involvement, clearly correlated by MRI findings, I would proceed with a 2-level anterior cervical discectomy with fusion using a plate and allograft. Postoperative, I would not use a collar and start range of motion early.

Community Case Discussion (0 comments)

SpineUniverse invites spine professionals to share their thoughts on this case.


Cancel
Delete

Get new patient cases delivered to your inbox

Sign up for our healthcare professional eNewsletter, SpineMonitor.
Sign Up!