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Cervical Spondylotic Myelopathy with Cord Compression

Patient History

A 65-year-old right-hand dominant lady presented with an 8-month history of left suboccipital and occipito-parietal pain and upper neck pain. Her pain was exacerbated by any head movements and radiated along the left arm. It was associated with numbness and paresthesias in the left hand fingers that waken her at night. She also complained of bilateral leg weakness; the left leg was weaker and gait imbalance.

The patient's past medical history includes type 2 diabetes mellitus and asthma. She sustained a whiplash injury 13-years ago after a road-traffic injury. She was pain-free for more than 7-years before her recent presentation. No history of rheumatoid arthritis.

Examination

On physical examination, this lady had a slightly limited cervical range of motion due to pain. She had some weakness in her left arm (4/5). Hyperreflexic left biceps reflex. Hoffmann's sign was absent bilaterally and her left toes had an extensor response on testing Babinski's reflex.

Blood Tests
Microcytic anemia. Elevated inflammatory markers (ESR and C-reactive protein). Negative rheumatoid factor and negative anti-nuclear antibody test. Negative TB skin test.

Images

Radiographic investigation of the cervical spine included the following:

A lateral view demonstrated widespread spondylosis and narrowing of the spinal canal at multiple levels.

A computed tomography (CT) scan showed a soft tissue mass effect at the level of C1-C2 along the posterior aspect of the odontoid process with significant compression of the dural sac and spinal cord posterior and towards the right side. Minimal erosive changes are noted to involve the bony structure. Degenerative changes were noted at the mid and lower cervical levels and involve mostly the facet joints but, also the disc spaces. Foramina encroachment were noted at the C3-C4 level on the right side and again at the C4-C5 level on the right side. Anterior osteophyte formation in multiple levels.

Preop CT scan, sagittal view, mass at C1-C2, cord compression
Figure 1A

Preop CT scan, sagittal view, mass at C1-C2, cord compression, degenerative changes
Figure 1B

Figures 1A-B. CT scans. Preoperative, sagittal reconstruction view, showing mass at the level of C1-C2 along the posterior aspect of the odontoid process with significant cord compression. Degenerative changes are noted at multiple levels.

MRI scans showed evidence of a pannus at the C1-C2 level with significant cord compression and subaxial spondylosis with cord compression.

Preop MRI T1, large pannus at C1-C2, cord compression, subaxial spondylosis
Figure 2A

Preop MRI T1, large pannus at C1-C2, cord compression, subaxial spondylosis
Figure 2B

Figure 2A-B. Preoperative MRI T1 with (upper view) and without (lower view) Gad. Large pannus at C1-C2 with significant cord compression, and subaxial spondylosis with cord compression.

Preop MRI T1, axial cuts at C1-C2 pannus, cord compression
Figure 3A

Preop MRI T1, axial cuts at C1-C2 pannus, cord compression
Figure 3B

Figures 3A-B. MRI T1 Axial cuts at C1-C2 level. Without (upper view) and with (lower view) Gad. Showing pannus compressing the spinal cord.

Preop MRI T2, sagittal view, pannus at C1-C2, cord compression, subaxial spondylosis
Figure 4. MRI T2. Preoperative sagittal view showing pannus at C1-C2 with significant cord compression and subaxial spondylosis with cord compression.

Diagnosis

Progressive cervical myelopathy with pannus at C1-C2 level with significant cord compression and subaxial spondylosis with cord compression.

A retro-odontoid non-neoplastic lesion associated chronic atlantoaxial subluxation is considered to be a pseudotumor and may present with or without instability.

The etiology of the pseudotumor remains controversial. An inflammatory pseudotumor is an idiopathic condition characterized by sclerosing inflammation, which mimics a neoplastic process. It is a rare condition and is usually indistinguishable from aggressive neoplasms or infection.

Suggest Treatment

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Selected Treatment

There is no place for nonoperative treatment in these kinds of cases. The goals of the surgical treatment in this case, include spinal cord and brain stem decompression, realignment of bone, and maintenance of cervical alignment with osseous fusion.

Surgical intervention is mandatory in cases with significant cord compression, myelopathic presentation, severe pain, or progressive neurological deterioration. Ventral medullary cervical junction and upper cervical cord decompression may be obtained by direct transoral approach. Anterior stabilization of the atlanto-axial complex is possible, but may need to be augmented with a posterior fusion. In cases with multiple level diseases, like our case, we think the best treatment option is the posterior approach.

Procedure
Image-guided, 3-dimensional, computer-assisted frameless stereotactic navigation; suboccipital decompression; C1-C7 bilateral cervical laminectomies, undercutting T1.

Occipital-cervical reconstruction with Mountaineer titanium instrumentation using midline occipital screws fixation, C1 lateral mass screws fixation, C2 pars/ pedicle screws fixation, C3-C7 lateral mass screws fixation, and T1 pedicle screws fixation.

Bone grafting with autogenously local bone graft supplemented with one unit bone morphogenic protein.

Monitoring upper and lower limbs somatosensory evoked potentials and segmental EMG activity during surgery.

Operative Details
Following essential fiberoptic intubation, general anesthesia was administered. The head was rigidly fixed with Mayfield pin fixation maintained in neutral position. The patient was rotated from the supine to a prone position on the Jackson table. All pressure points were carefully padded. Preoperative antibiotics and dexamethasone were administered. BrainLab dynamic reference frame was clamped onto the Mayfield head clamp. The Arcadis Siemens CT fluoroscopy unit was then brought into the field. We performed a spin-CT to obtain 3-dimensional CT-type images. These were then transferred over to the BrainLab unit for intraoperative image guidance.

BrainLab in action, used to select the best trajectory for C1 screws
Figure 5A

BrainLab in action, used to select the size and length of C1 screws
Figure 5B

Figure 5A-B. BrainLab in action. Upper view when we were selecting the best trajectory for C1 screws. Lower view when we were selecting the size and length of the screws for C1.

We chose a midline posterior occipital cervical approach. A high-speed coarse diamond bur was used to fashion a small suboccipital craniectomy. Then we burred down the lamina from C1 to the upper portion of T1. The decompression was completed with microsurgical punches fashioning the bilateral foraminotomies and thoroughly decompressing the cord from the skull base down to the top of T1.

We then used the BrainLab image-guided system, as well as the lateral fluoroscopy unit, to place C1 and C2 screws (32-mm partially threaded and 24-mm fully threaded Mountaineer polyaxial screws, respectively) bilaterally. We then cannulated the lateral masses from C3 to C7 and placed 14-mm screws. At T1 we placed 22-mm screws. Occipital plate and rods were placed and secured.

We placed two Crosslinking devices at C2 and C7 for additional rotational control.

We morselized the local bone graft using a bone mill. A large unit of bone morphogenic protein was injected into the collagen sponge, which was divided into 4 longitudinal strips. The morselized bone graft was placed over the collagen sponge strips and packed from the occiput down to T1 bilaterally.

The wound closed in layers. Postoperatively, the patient woke uneventfully, and moved her arms and legs satisfactorily. The neck was rigidly mobilized in a hard cervical collar.

Postop CT scan, sagittal reconstruction view
Figure 6. Postoperative CT scan, sagittal reconstruction view.

Outcome

The patient was discharged home a few days later, walking normally with no pain and no neurological deficit. She will be seen in our outpatient clinic in 6 weeks.

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