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Cervical Myelopathy: Progressive Problems with Balance and Handwriting

History

This 54-year old male has a prior history of a herniated disc at C5-C6. He had an anterior cervical discectomy and fusion (ACDF) peformed 8 years ago for arm pain and radiculopathy. He did well for many years following that surgery. In the past 8 months, the patient has had progressive problems with balance and handwriting. He has also had clumsiness with his hands. However, he has no arm pain, neck pain, or discomfort in his neck.

Examination

On examination, the patient is unable to do a tandem walk without losing his balance. He has 3+ increased reflexes throughout his upper and lower extremities with bilateral Hoffmann’s reflexes in both hands. His motor strength and sensory exam are normal throughout. 

Prior Treatment

As mentioned above, the patient had ACDF at C5-C6 8 years ago. He did very well for many years but over the past 8 months had started developing the symptoms stated above. He tried some physical therapy, but this did not help.

Pre-treatment Images

Fig 1 Wang Pre-op AP and Lateral X-rays

Fig 1 Wang Pre-op AP and Lateral X-rays
Figure 1: Pre-op AP x-ray (left) and lateral x-ray (right) demonstrate a solid fusion at C5-C6 from prior surgery. There are degenerative changes throughout the cervical spine with slight straightening of the cervical lordosis. There is some mild lordosis remaining.

 

Fig 2 Wang Pre-op Sagittal MRIsFigure 2: Pre-op sagittal MRIs show prior fusion at C5-C6 with herniated discs and stenosis at C3-C4, C4-C5, C6-C7, and C7-T1. There are cord signal changes of edema above and below the areas of the prior spinal fusion.

Diagnosis

The patient was diagnosed with adjacent segment disease and cervical stenosis leading to cervical myelopathy.

Suggest Treatment

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Selected Treatment

The patient had a cervical laminaplasty because cervical stenosis and myelopathy were present above and below the prior fusion from C3-C4 all the way down to C7-T1. Although he had multiple level involvement, he did not have symptoms of neck pain.

There was some lordosis present, which allowed for a posterior approach for decompression, and since there were no signs of instability on flexion/extension radiographs (not shown), a fusion was not necessary.

Post-treatment Images

 Fig 3 Wang Post-op AP and Lateral X-raysFigure 3: Post-op AP x-ray (left) and lateral x-ray (right) show the laminaplasty plates in good position with good preservation of the pre-operative alignment.

Outcome

It has been 2 years after the patient’s surgery, and he has recovered significantly. He no longer has balance issues or clumsiness. He is still slightly hyper-reflexic but much less so compared to his previous surgery.

Case Discussion

This relatively young patient presents with myelopathy and no evidence of radiculopathy. He has no neck pain and some preservation of lordosis. It is assumed he still has some motion, although this is not mentioned in the clinical presentation provided. Given this scenario, laminoplasty is the most reasonable treatment option. The surgery was performed well and the result was good at last follow up.

What if the presenting picture was different? There are a number of issues that would alter the decision-making process.

If the patient had significant neck pain in the absence of radiographic evidence of instability or facet disease, laminoplasty is probably still the best first option. If there was a single-level radiculopathy in association with the myelopathy, then a properly focused foraminotomy with laminoplasty should be effective.

The situation changes if there were multi-level radiculopathies, particularly if they were bilateral, and this patient has shown a tendency toward disc degeneration. The value of foraminotomy decreases with the severity of disease and particularly the number of levels requiring treatment. Multi-level radiculopathy in the settling of myelopathy is usually better addressed with anterior decompressions and fusions at C3-C4,C4-C5, C6-C7, and C7-T1, depending on the level of clinically significant radiculopathy. If all segments required treatment, I would favor backing up the construct with posterior fixation. Anterior approaches allow for excellent canal decompression and direct and indirect foraminal decompression.

Finally, the preservation of at least some lordosis is critical. Without lordosis, the ability to adequately decompress the spinal cord via a posterior route is markedly diminished when there is anterior canal compromise. If the spine was straight or kyphotic, then the anterior-posterior decompression fusion would be mandatory.

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