Unsteady Gait and Pain in Upper Limbs: Which Approach Is Best?

History

The patient is a 61-year-old male auto worker.  He presents with a one-year history of progressively worsening:

• Unsteady gait
• Fine motor dysfunction
• Pain in both upper limbs
• Urinary urgency and frequency

Examination

Examination reveals:

• Difficulty with tandem gait
• Hoffman’s positive bilaterally
• Hyper-reflexia throughout
• Grade 4/5 power in deltoids and biceps
• Increased tone in lower limbs
• Nurick 2

Prior Treatment

There was no prior treatment.

Pre-treatment Images

Figure 1: Sagittal x-ray. Image courtesy of Michael G. Fehlings, MD, and SpineUniverse.com.

Figure 2: Flexion-extension x-rays. Image courtesy of Michael G. Fehlings, MD, and SpineUniverse.com.

Figure 3: Sagittal CT scan. Image courtesy of Michael G. Fehlings, MD, and SpineUniverse.com.

Figure 4: Sagittal MRI. Image courtesy of Michael G. Fehlings, MD, and SpineUniverse.com.

Figure 5: Sagittal MRI. Image courtesy of Michael G. Fehlings, MD, and SpineUniverse.com.

Figure 6: Axial MRIs of affected levels. Image courtesy of Michael G. Fehlings, MD, and SpineUniverse.com.

Diagnosis

Multilevel spondylosis with cord compression and preserved lordosis

Selected Treatment

Posterior laminectomy and fusion

Post-treatment Images

Figure 7: Sagittal CT. Image courtesy of Michael G. Fehlings, MD, and SpineUniverse.com.

Figure 8. Image courtesy of Michael G. Fehlings, MD, and SpineUniverse.com.

Figure 9.Image courtesy of Michael G. Fehlings, MD, and SpineUniverse.com.

Figure 10: Post-operative sagittal x-ray. Image courtesy of Michael G. Fehlings, MD, and SpineUniverse.com.

Outcome

The patient is now one-year post-op, and he reports decreased pain and numbness.  He feels stronger, and he has no bowel/bladder problems.

At his one-year follow-up, examination showed:

• Hoffman’s positive bilaterally
• Mild hyper-reflexia
• Normal tone
• Normal power throughout
• Normal gait
• Normal tandem

One-year Post-op Images

Figure 11: Sagittal MRI one-year following surgery. Image courtesy of Michael G. Fehlings, MD, and SpineUniverse.com.

Figure 12: Axial MRIs of affected levels from one-year after surgery. Image courtesy of Michael G. Fehlings, MD, and SpineUniverse.com.

Case Discussion

Paul C. McCormick, MD, MPH, FACS

Professor of Clinical Neurosurgery

Columbia University College of Physicians and Surgeons

This patient presents with progressive myeloradiculopathy from multilevel cervical stenosis with spinal cord compression. It is most severe at the C3-C4 level due to a large disc herniation. Upright plain films of the cervical spine demonstrate a lordotic cervical spine alignment without segmental instability or kyphotic angulation on flexion/extension views.

Based on the multilevel nature of the spinal stenosis, retained lordotic alignment on upright imaging, and lack of segmental instability on dynamic imaging, I agree with the treatment decision to perform multilevel cervical laminectomy with fusion from C2-T1.  Cervical laminoplasty would also be an appropriate treatment choice in this patient.  An anterior approach could be considered, but I would be concerned with the potential morbidity that can be associated multilevel anterior cervical procedures, especially those extending to the upper cervical spine (eg, C3-C4).

The patient experienced a satisfactory recovery and post-operative imaging at one year demonstrates excellent spinal cord compression. Not surprisingly, the C3-C4 herniated disc has resorbed.  There is some loss of the lordotic contour following the fusion but the spine is stable and the primary objective of safe, effective, and durable spinal cord decompression and spinal stabilization have been expertly accomplished.