Cervical Degenerative Disease

History

The patient is a 67-year-old male who presented with neck pain and mild radiation into both shoulders.

Examination

The patient's neurological examination showed 5/5 strength, normal sensation, some slight difficulty with tandem gait, and normal reflexes. His Babinski response was negative and Hoffman's sign was bilaterally positive.

Images

Figure 1. Sagittal MR shows disc space collapse at C5-C6, C6-C7, with disc bulging at C5-C6, C6-C7, and C7-T1.

Axial MRs (Figures 2A, 2B, 2C) show severe spinal stenosis secondary to congenital stenosis and disc bulging at C5-C6, C6-C7 and C7-T1 with T-2 signal change at C6.

Figure 2A. C5-C6

Figure 2B. C6-C7

Figure 2C. C7-T1

Diagnosis

Cervical myelopathy secondary to severe stenosis and cervical degenerative disc disease.

Selected Treatment

ACDF at C5-C6, C6-C7 with allograft using a translational plate.

Figure 3. Postoperative AP x-ray, ACDF at C5-C6, C6-C7.

Figure 4. Postoperative lateral x-ray, ACDF at C5-C6, C6-C7.

Outcome

The patient had returned to near normal gait and balance by his 3-month postoperative visit.

Case Discussion

This patient has neck and shoulder pain but little clinical evidence of myelopathy. His MR shows reversal of normal cervical lordosis and disc space collapse at C5-C6 and C6-C7. There appears to be some congenital spinal stenosis, which combined with disc bulging and osteophyte formation, results in spinal cord compression at C5-C6, C6-C7, and C7-T1. There is increased signal within the cord posterior to the C5-C6 disc. There is hypertrophy of the ligamentum flavum at C5-C6 and C7-T1.

The high signal within the cord indicates the compression is significant despite the lack of clinical findings. Since his neurological examination is almost normal, one has to assume the reason he sought medical attention was for neck pain. Even with some reversal of lordosis, this situation could be well-decompressed via laminoplasty, but there should be concern about this leaving the patient with persistent neck pain.

I would treat the patient with a 3-level anterior decompression and arthrodesis at C5-C6, C6-C7, and C7-T1. Although the caudal level is probably not currently causing a problem, it would be relatively easy to deal with at this time rather than subject the patient to further surgery later.