SpineUniverse Case Study Library

Cervical Spine Multiple Myeloma With Kyphotic Deformity and Cervical Myelopathy

History

The patient is a 60-year-old female with a history of multiple myeloma and worsening mechanical neck pain. Associated symptoms include increased arm and leg weakness with numbness and gait difficulties.

Examination

There is diffuse numbness in both arms and legs, but she can walk with significant assistance.

On examination, the patient is awake and responsive, and oriented to person, place and time. The cranial nerves (II-XII) are intact, no pronator drift, and bilateral upper and lower extremities are 4/5 throughout.

There is hyperreflexia throughout, Hoffman’s sign on the right side, no clonus, and toes are downgoing.

Pre-Treatment Imaging

Figures 1A-1D (below) respectively demonstrate cervical spine MRIs with/without gadolinium shows a large C5-C6 epidural tumor causing severe spinal cord compression and kyphotic deformity. The cervical spine CT images show diffuse osteolytic lesions involving the patient’s cervical and thoracic spine; the most severe osteolytic lesions involve C5, C6 and the lower half of C4.

Cervical MRI with gadolinium shows a large C5-C6 epidural tumorFigure 1A. Cervical MRI with gadolinium shows a large C5-C6 epidural tumor.

Cervical MRI without gadolinium shows a large C5-C6 epidural tumorFigure 1B. Cervical MRI without gadolinium shows a large C5-C6 epidural tumor.

Cervical CT scan shows diffuse osteolytic lesionsFigure 1C. Cervical CT scan shows diffuse osteolytic lesions.

Cervical CT scan shows diffuse osteolytic lesionsFigure 1D. Cervical CT scan shows diffuse osteolytic lesions.

Diagnosis

C5-C6 epidural tumor with myelopathy and kyphotic deformity.

Suggest Treatment

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Selected Treatment

Stage I anterior C4, C5 and C6 corpectomy with cage placement followed by stage II posterior C2-T2 instrumented fusion.

Surgeon's Rationale
We chose a 3-level cervical corpectomy given that the tumor involved C5 and C6 and the lower half of C4, and followed with posterior stabilization.

Post-Operative Imaging

Figures 2A-2C (below) respectively are cervical spine x-rays showing the C4, C5 and C6 corpectomy with an expandable PEEK cage and plate with posterior C2-T2 instrumented fusion, and demonstrates improved cervical spinal alignment. At 6-months post-op, the cervical spine MRI shows satisfactory decompression of the spinal cord.

Post-operative cervical x-ray shows C4, C5 and C5 corpectomy with expandable PEEK cage and plateFigure 2A. Post-operative cervical x-ray shows C4, C5 and C5 corpectomy with expandable PEEK cage and plate.

Post-operative cervical x-ray shows the posterior C2-T2 instrumented fusionFigure 2B. Post-operative cervical x-ray shows the posterior C2-T2 instrumented fusion.

Post-operative cervical x-ray shows improved cervical spine alignmentFigure 2C. Post-operative cervical x-ray shows the improved alignment of the cervical spine.

Outcome

The patient did very well after surgery. She did experience some post-operative dysphagia that improved upon discharge. Her mechanical neck pain completely was resolved.

At 6-months post-op, she has normal strength and sensation throughout her upper and lower extremities. She can walk normally and carry on her daily life activities.

Case Discussion

This is a great case example of a tumor that has compromised the stability of the cervical spine, and is causing severe compression of the spinal cord, with resultant neurological issues. In addition, the spine is falling into kyphosis, which can progress and cause significant problems with sagittal alignment, and more tethering or “kinking” of the spinal cord, with likely progressive damage.

The CT scan clearly shows the lack of osseous support in the anterior column. The approach chosen is absolutely appropriate and looks to have been quite successful. The anterior approach to both decompression of the spinal cord and resection of the tumor, is the initial approach of choice. In addition, this allowed for correction of the kyphosis, and visualization of the cord.

The reconstruction of the spine with the anterior support is critical for long-term stability. I also agree with the posterior supplementation, given the possible lack of healing of the anterior construct. The result appears to be excellent, and the patient appears to be doing well. I consider this a very nicely performed surgery that has led to significant benefit to the patient.

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