Cervical myelopathy can lead to life-altering nerve pain, including numbness, tingling, even paralysis. Joshua J. Wind, MD, neurosurgeon at Washington Neurosurgical Associates in Washington, DC, explains how he successfully treated a patient who had both cervical myelopathy and spinal deformity—allowing her to enjoy the activities she loves without constant neck pain.
Lois picked up playing golf while at university and has been an avid enthusiast her entire life. On weekends, when she sees her teenage grandson, they often practice their putting. A few months ago, Lois’ neck started to hurt. At first, she thought it was just arthritis and carried on. However, her neck pain worsened, and new symptoms developed—numbness and odd tingling sensations started to affect her left arm. Next, her left hand and some fingers didn’t work well. She became clumsy, and buttoning her blouse became challenging.
Dr. Wind: Lois was referred to me by her primary care doctor immediately after she told him about the symptoms in her hands. She came to my office with a set of x-rays of her neck but no advanced imaging (that is, an MRI).
Q: During Lois’ first appointment, what was significant about her presentation and medical history?
Dr. Wind: Lois' symptoms were very suspicious for cervical myelopathy. Myelopathy means an abnormal function of the spinal cord. It is most commonly found in the neck, where the spinal cord can be compressed by degenerative changes in the spine (these can include arthritis and degenerative disc disease of the cervical spine).
When these degenerative processes lead to pressure on the spinal cord, eventually dysfunction of the spinal cord occurs. This spinal cord dysfunction causes symptoms such as numbness and tingling, loss of dexterity of the hands, and eventual weakness of the hands. In advanced cases, it will cause stiffness and weakness of the legs, and can eventually lead to an inability to walk or even paralysis.
Lois described vague numbness and tingling in her hands, as well as difficulty with clumsiness of her hands. She also had numbness and tingling in her right leg. All these findings suggested a problem involving pressure on the spinal cord in the neck.
Q: Tell us about Lois’ physical and neurological examination. What did you discover?
Dr. Wind: Lois' physical exam increased the suspicions of cervical myelopathy. Her reflexes were too active, meaning they were abnormally jumpy and reactive. She also had some abnormal reflexes—reflexes that are normally not present but will be visible when the spinal cord is compressed.
Lois also had a finding called Lhermitte's phenomenon, which occurs when bending the neck or applying downward pressure on the head while the neck is flexed causes electric shock sensations. This also suggests a problem with the spinal cord.
Q: Did Lois need radiographic imaging, such as CT or MRI?
Dr. Wind: Based upon the concern for myelopathy, I sent Lois for an MRI, CT, and some special x-rays of her neck with her moving her head forward and backward.
The MRI gave me the best view of her spinal cord and nerves, and the degree and location of the pressure on the spinal cord. The CT scan gave me a good look at the bony structure of the neck, and the x-rays allowed me to see how those bones moved between bending the neck backward and forward.
Dr. Wind: Based upon the imaging I obtained, Lois had cervical spinal stenosis and myelopathy, leading to her spinal cord compression and symptoms. She also had deformity of her cervical spine, which was caused by the individual vertebrae in her neck being out of normal alignment. The C3 vertebra was slipped forward significantly on the C4 vertebra, and similarly the C4 vertebra was slipped forward on C5—this slip is called listhesis. This abnormal alignment contributed to the compression of her spinal cord, as well as to her neck pain.
I described these findings to Lois, and I explained that they were all due to the unique way that the degenerative processes had played out in her spine.
Q: Please describe your thought process as you developed her treatment plan. Was cervical spine surgery Lois’ only treatment option?
Dr. Wind: While most spinal patients can be successfully treated with conservative, non-operative treatment, there are some conditions for which surgery is the recommended option. One of these is when there is compression of the spinal cord coupled with signs and symptoms of spinal cord dysfunction—myelopathy.
When the spinal cord is no longer functioning normally, decompression through surgical treatment is often recommended to stop the progressive loss of function.
Q: What treatment did you recommend and why?
Dr. Wind: I recommended surgical treatment for Lois. The more complicated discussion was on how to accomplish surgery.
There are several ways to decompress the spinal cord and treat the deformity, including surgery from the front of the neck, surgery from the back of the neck, as well as a combination of the two.
Ultimately, I chose a combined surgery from both the front and back of the neck due to the degree of compression of the spinal cord, as well as the underlying deformity. Performing a combined approach allowed me to have a higher chance of success to thoroughly decompress the spinal cord, improve alignment and deformity, and achieve a successful fusion.
Q: How was Lois’ surgery performed?
Dr. Wind: The first part of the surgery was an anterior cervical discectomy and fusion (ACDF) between the C3 and C6 levels. This procedure involves an incision on the front of the neck, where we then access the spine. We remove the entire disc between two vertebrae, allowing decompression of the spinal cord and nerves. We then place a spacer in the empty space where the disc was, and the spacer allows bone to grow through it, eventually creating a solid bony fusion. This was performed at the disc space between C3 and C4, C4 and C5, and C5 and C6.
Once completed, a plate was placed and secured with screws anchoring it to the vertebrae, which acts as a rigid internal brace or cast while the bony healing process occurs. This plate also allowed us to pull the vertebrae back into neutral alignment, thus addressing the deformity and listheses.
An ACDF is performed through a relatively small incision on the front of the neck. There is no real muscle disruption with this approach, so it is very well tolerated by patients.
The second part of the operation was from the back of the neck. It involved removing some of the bone covering the spinal cord to further decompress the spinal cord. I also placed screws and rods to further support the fusion and the deformity correction. I did this through a 3-inch incision.
Q: How was her post-operative pain managed in the hospital?
Dr. Wind: Lois took pain medications and muscle relaxants after surgery for several weeks for pain control. She was in the hospital for 3 days, primarily to allow her to have physical therapy to help improve her mobility before going home.
Q: Did Lois need to wear a brace and external spine bone growth stimulator?
Dr. Wind: Lois wore a cervical collar for 6 weeks after surgery, and she used an external bone growth stimulator for 6 months after surgery. Both of these were used to increase bone healing and the success of fusion after surgery.
Q: What was Lois’ treatment outcome? How is she doing today?
Dr. Wind: Lois has done well. Her hand function returned to normal, and her numbness and tingling symptoms greatly improved. She is back to her normal activity, including returning to the golf course.