Cervical and Bilateral Arm Pain

History

The patient is a 46-year-old Caucasian female with a 2-year history of neck and bilateral arm pain, right greater than left.

Examination

The patient had pain on hyperextension of the cervical spine. Symmetric reflexes. Some triceps weakness on the right compared to left.

Prior Treatment

She underwent nonoperative treatment with medication and physical therapy for a period greater than 6-months without response.

Images

Pre-operative radiographs, including plain films, CT, and MRI show evidence of loss of normal cervical lordosis, with some degenerative osteophytes present at C5-C6 and C6-C7. (Figures 1, 2)

Figure 1

Figure 2

The MRI shows a pre-operative bulge at C6-C7 with a focal high intensity herniation and C5-C6 with an asymptomatic vertebral hemangioma in the vertebral body of C5. (Figure 3)

Figure 3

Diagnosis

Cervical degenerative disc disease.

Selected Treatment

The patient underwent a 2-level ACDF with allograft and instrumentation using a 2-level SlimFuse™ plate. The single screw per level enables a much narrower profile compared to the standard 2 screws per level plates.

The hemangioma did not bleed excessively during surgery and had no effect on the patient's postoperative outcome. She experienced almost immediate resolution of her arm discomfort and was discharged the next morning following surgery. No immobilization was used.

Postoperative x-rays at 3-months (Figure 4) and 6-months (Figure 5, 6) show maintenance of normal cervical lordosis with, what appears to be, complete incorporation of the cervical allograft.

Figure 4

Figure 5

Figure 6

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Outcome

The patient had less than a 24-hour hospital stay with virtually no dysphagia, which may be attributed to the plate system used, although a larger number of cases need to be followed to make that determination. Six-month follow-up suggests the fusion is solid and the patient continues to do well.

Case Discussion

This case demonstrates the excellent results we can reliably expect when performing anterior decompression and fusion for cervical radiculopathy. I agree that the C5 lesion appears to be a classic hemangioma and I also agree with including both the C5-C6 and C6-C7 disc spaces in the construct. Whether or not the supra-adjacent disc is symptomatic, its inclusion is probably responsible for a lower rate of additional adjacent segment disease.

Whether or not a single screw per body / narrower plate is responsible for reduced dysphagia certainly remains to be proven. However the concept is novel, sensible and appears viable (as long as fusion rates are equivalent).

Author's Response

As I have come to expect over the years, Dr. Albert's comments are insightful, succinct, and right on the money. We are currently in the process of examining the fusion rate of this device in a prospective cohort study with minimum 2-year follow-up.