Cervical Myelopathy in a 74-Year-old Pediatrician

Patient History

The patient is a 74-year-old female practicing pediatrician whose symptoms have progressed over a 6-month period. She reports progressive left arm numbness, wasting of the thenar muscles, tingling in her hands, loss of hand dexterity, and bilateral heaviness in her legs with an ataxic gait.

Examination

She is 5'2" and weighs 130 pounds. She is a non-smoker. There is pain and exacerbation of numbness with arm extension. She has 3+ /5 biceps and wrist flexion on her left side. She exhibits decreased reflexes in her upper extremities and bilateral Hoffman's reflex. Clinically, she has no gait abnormality.

Prior Treatment

Except for some physical therapy, no treatment.

Images

Figure 1. Lateral cervical radiograph with no change with flexion / extension; there is mild loss of lordosis.

Figure 2. Lateral cervical MRI shows cervical myelopathy. There is marked canal stenosis at C4-C6 with herniations at C4-C5 and C5-C6, and posterior osteophytes at C4-C6.

Moderate to severe stenosis with broad-based disc protrusions and spondylotic bars. (Figures 3A-3C)

Figure 3A. C3-C4

Figure 3B. C4-C5

Figure 3C. C5-C6

Diagnosis

Cervical myelopathy with compression at C3-C4, C4-C5, C5-C6.

Selected Treatment

The patient underwent a 3-level ACDF with decompressive laminectomy at C3- C6 and posterior stabilization with allograft.

Figure 4A. Postoperative lateral radiograph.

Figure 4B. Postoperative posterior radiograph.

Outcome

At 6-months postop, she is doing well. Her neurologic symptoms, except residual hand tingling, are resolved. She returned to work full-time as a pediatrician.

At one-year postop, she maintains a solid fusion and her clinical condition is very good.

Case Discussion

This is a case of progressive cervical myelopathy in a functioning 74-year-old female. What is not mentioned in the history is the presence or absence of axial neck pain, which will have implications if one considers laminoplasty. There are multiple options for this patient, ranging from an anterior alone, laminectomy with fusion, anterior / posterior, or a laminoplasty. There is evidence in the peer-reviewed medical literature that would suggest the clinical outcomes from any of the options are similar. However, multilevel anterior surgery is associated with higher complications (e.g. dysphagia).

My personal preference would be a dorsal procedure, preferably laminoplasty, if she does not have significant neck pain. Following the dorsal procedure, I would follow the patient clinically. An anterior procedure would be predicated at that time by her clinical recovery or lack thereof, and the presence of persistent ventral compressive pathology on postoperative imaging.