Cervical Myelopathy: Difficulty with Rapid Fine Hand Movements
A 64-year-old man had a C4-C6 laminectomy performed 3 years ago for myelopathy due to stenosis. His myelopathy improved, and he did well for a year.
He then began to develop increasing neck pain, and his myelopathic symptoms began to return. Additionally he began to have great difficulty holding his head up.
Clinically, his neck alignment appeared to be normal when he was supine.
On examination, his head was markedly flexed in neutral. He had difficulty with rapid fine movements of his hands. His gait was slow and stiff. He had bilateral Hoffman’s signs and positive Babinski’s signs.
Figure 1: Neutral lateral radiograph
Figure 2: Midsagittal CT scan demonstrates marked improvement in alignment.
Figure 3: Sagittal T2-weighted MRI shows loss of lordosis and a disc herniation and obvious stenosis at C6-C7.
Figure 4: Axial MRI at C4 demonstrates consistent cord compression.
The patient was diagnosed with cervical myelopathy.
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The patient was treated with anterior C3-C4, C4-C5, C5-C6, C6-C7, and C7-T1 decompressions and fusions. The patient also had a C3 to T1 posterolateral instrumented fusion, all under a single anesthesia.
Figure 5: An early post-operative lateral radiograph showing instrumentation.
Figure 6: CT scan at 1-year post-surgery shows restoration of lordosis and solid arthrodeses at each level.
The patient’s lordosis was restored, and his myelopathic symptoms resolved. At 1-year post-surgery, he had minimal neck pain.
This is an interesting patient with a superb technical result facing a common but challenging problem for any surgeon dealing in cervical spine disorders.
Postlaminectomy kyphosis has been reported to occur in up to 20% of patients who have loss or lordosis preoperatively. The cause of the myelopathy is probably vascular with draping of the cord over the anterior osteophytes.
The challenge is in the reconstruction. In this example, an extensive anterior/posterior reconstruction is performed with a 5-level anterior fusion and decompression.
We know that multilevel anterior level decompressions and interbody fusions work better than corpectomies in restoring lordosis.
How many levels are enough? With a prior posterior approach and multiple levels, adding a posterior tension band is very reasonable and extending it into the thoracic spine appropriate.
I think the surgeon should be congratulated on demonstrating amazing technical ability to perform a 5-level approach from the front.
This is my only point of contention. He appears to have a somewhat flexible kyphosis. On the CT, he is not kyphotic. C3-C4 has also not been decompressed.
At 64, having a high and simultaneous neck dissection puts him at risk of profound and persistent dysphagia. Not all instrumentation sets are made for 5 levels as well and it may force the surgeon to use an unfamiliar system.
In my hands, I probably would have limited the anterior reconstruction to 3 levels, C4-C7 and then decompressed C3-C4, C6-C7 and C7-T1 posteriorly in addition to the C3-T1 instrumentation. I think this would have achieved the goals of correction of sagittal balance, decompression and stabilization with hopeful improvement of myelopathic symptoms without adding the morbidity associated with a 5 level anterior dissection. Nevertheless, this is another option to what is a surgical very well managed case.