SpineUniverse Case Study Library

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


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 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

Sagittal x-ray from a spine surgery caseFigure 1: Sagittal x-ray

Flexion-Extension x-rays for multilevel CSM spine caseFigure 2: Flexion-extension x-rays

Sagittal CT of cervical spineFigure 3: Sagittal CT scan

Pre-op sagittal MRI of cervical spineFigure 4: Sagittal MRI

Pre-op sagittal MRI of the cervical spine in multilevel CSM caseFigure 5: Sagittal MRI

Axial MRIs of affected levels in cervical spineFigure 6: Axial MRIs of affected levels


Multilevel spondylosis with cord compression and preserved lordosis

Suggest Treatment

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Selected Treatment

Posterior laminectomy and fusion

Post-treatment Images

Post-op sagittal CT showing spinal instrumentationFigure 7: Sagittal CT

CT following surgery for multilevel CSMFigure 8

Spinal instrumentation in the cervical spine Figure 9

Post-op x-ray on mutlilevel CSM patientFigure 10: Post-operative sagittal x-ray


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

Sagittal MRI one-year following cervical spine surgeryFigure 11: Sagittal MRI one-year following surgery

One-yr axial MRIs of cervical spine surgery patientFigure 12: Axial MRIs of affected levels from one-year after surgery


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)

SpineUniverse invites spine professionals to share their thoughts on this case.

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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