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
Diagnosis
Multilevel spondylosis with cord compression and preserved lordosis
Suggest Treatment
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Posterior laminectomy and fusion
Post-treatment Images
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
Case Discussion
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.
Community Case Discussion (2 comments)
Skip Laminectomy is a muscle preserving procedure, which is very convenient in this multilevel case presented. That option was not offered as a valid surgical treatment. I would choose not to fuse, since this patient does not seem to need it. Although multiple level decompression through posterior laminectomy en fusion was the treatment of choice and the patient is doing well, loss of motion and cervical lordosis to me is a last resort treatment. Thank you for sharing this very interesting case.
I agree that posterior approach is the best choice in this patient. Laminoplasty and skip laminectomy were also legitimate choices, however, I would personally go with laminectomy plus fusion as the authors did, because it gives the best chance for resolution of anteriorly compressing discs, and easing neck pain (which has not been mentioned).
Although the laminectomy plus fusion is a wise choice and executed very well in this patient, I believe that the patient has been over-treated. C2 and C7 laminectomies were clearly not necessary in this patient. I would proceed with C3 to C6 laminectomies, and removing only upper part of the C7 vertebra (=arcocristectomy). Then, would apply C3-C6 lateral mass fixations only. That would be enough for the myelopathic symptoms, and preserving muscle attachments of C2 and C7 spinous processes would cause a better functioning head and neck movements.
The authors seems being horrified by the neurological symptoms, and forget about side symptoms such as neck pain and discomfort due to overly long fusion. Those are generally less important symptomatology for the surgeon, however, very important for the patient, especially in the long run. A common mistake.
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