Recurrent Myelopathy and Adjacent Segment Disease
Myelopathy Returns 3 Years After Surgery
The patient is a 46-year-old male who presented with progressive myelopathy in 2009. There is no history of trauma, nor is there a precipitating event. Besides the myelopathy, he is an otherwise healthy individual.
Spastic myelopathy is noted on examination.
There is no prior treatment.
Cervical myelopathy from disc herniation at C5-C6
Suggest TreatmentIndicate how you would treat this patient by completing the following brief survey. Your response will be added to our survey results below.
Single-level corpectomy and fusion at C6. The myelopathy was resolved at that point.
Further Development: 3 Years After Surgery
In 2012 (3 years after the single-level corpectomy and fusion), the patient presented with recurrence of myelopathy that had developed over a period of several weeks. He had numb, clumsy hands and difficulty walking.
MR showed adjacent disc herniation at C4-C5.
Because the cord compression was ventrally located, an anterior approach was indicated. The options were:
- Remove the plate, perform a discectomy at C4-C5, put in new interbody graft, put in new plate at C4-C5: However, removing the plate carries risks (eg, recurrent laryngeal nerve injury, dysphagia).
- Leave the plate, perform a discectomy at C4-C5, put in a low-profile interbody PEEK device: This was selected as the treatment option to address the recurrent myelopathy.
Post-treatment Images: After Surgery for Adjacent Segment Disease
The patient is now 6 months post-operative, and clinically, the patient has done fine. There is resolution of myelopathy.
Concerns with the approach in addressing the recurrent myelopathy in 2012:
- The low-profile interbody devices don’t give you a lot of surface for bone grafting. Make sure you augment the cage with enough bone graft so that the fusion can occur.
- Sagittal alignment is slightly kyphotic at the C4-C5 level. One of the concerns is that post-operative suboptimal sagittal alignment may be a potential risk factor for future adjacent segment disease at the rostral level (C3-C4).
This case demonstrates a common scenario in cervical spondylosis. A middle aged male presents with myelopathy secondary to a disc herniation at C5-C6 with underlying spondylosis at C6-C7 in the presence of a congenitally narrow canal. Initial surgical treatment was well addressed anteriorly with a C6 corpectomy with other viable options of a two-level discectomy or a single-level C5-C6 discectomy. The patient had made an excellent recovery following the procedure however, presents 3 years later with a similar disc herniation proximal to the fusion.Adjacent segment problems are a common phenomena following spinal fusions. Possible contributors to the proximal failure in this case include the persistent kyphosis that remains between C5 and C7, the proximal position of the anterior plate and the two-level fusion that exists between C5 and C7. There are various options available for treatment of this new disc herniation, which were delineated in the case. With the persistent kyphosis existing between the original construct, an opportunity presented with this new surgery to lengthen the anterior column and perhaps decrease the risk of a similar problem presenting at the next level. To achieve this, I feel removal of the previous plate and placement of a large lordotic-shaped structural graft, with a new plate either extending from C4-C5 or from C4 to C7 would have dealt with the two issues of adjacent segment disc herniation and focal cervical kyphosis. A PEEK stand-alone device was used in this case that does not require removal of the plate. While this implant is lordotic in shape, and has been perfectly placed from a technical standpoint, it leaves minimal surface area for fusion and does not provide adequate lordosis to deal with the deformity in this case.