SpineUniverse Case Study Library

Recurrent Myelopathy and Adjacent Segment Disease

Myelopathy Returns 3 Years After Surgery


The patient is a 46-year-old male who presented with progressive myelopathy in 2009. There is no history of trauma, nor is there a precipitating event. Besides the myelopathy, he is an otherwise healthy individual.


Spastic myelopathy is noted on examination.

Prior Treatment

There is no prior treatment.

Pre-treatment Images

Sagittal MRI in adjacent segment disease caseFigure 1: Sagittal MR. Note large central disc herniation with significant cord compression at C5-C6. There are degenerative changes at C6-C7. Image courtesy of Paul C. McCormick, MD, and SpineUniverse.com.

Pre-op Axial MRIs of C5-C6 and C6-C7Figure 2: C5-C6(top), C6-C7 (bottom). There are degenerative changes and narrowing of the disc, but no nerve root or cord compression at C6-C7. Image courtesy of Paul C. McCormick, MD, and SpineUniverse.com.



Cervical myelopathy from disc herniation at C5-C6

Suggest Treatment

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Selected Treatment

Single-level corpectomy and fusion at C6. The myelopathy was resolved at that point.

Further Development: 3 Years After Surgery

In 2012 (3 years after the single-level corpectomy and fusion), the patient presented with recurrence of myelopathy that had developed over a period of several weeks. He had numb, clumsy hands and difficulty walking.

MR showed adjacent disc herniation at C4-C5.

Sagittal MR showing adjacent segment disease at C4-C5Figure 3. Image courtesy of Paul C. McCormick, MD, and SpineUniverse.com.

Because the cord compression was ventrally located, an anterior approach was indicated.  The options were:

  • Remove the plate, perform a discectomy at C4-C5, put in new interbody graft, put in new plate at C4-C5:  However, removing the plate carries risks (eg, recurrent laryngeal nerve injury, dysphagia).
  • Leave the plate, perform a discectomy at C4-C5, put in a low-profile interbody PEEK device:  This was selected as the treatment option to address the recurrent myelopathy.

Post-treatment Images:  After Surgery for Adjacent Segment Disease

Post-op x-ray showing spinal instrumentationFigure 4: Sagittal x-ray showing instrumentation following surgery to address recurrent myelopathy. Image courtesy of Paul C. McCormick, MD, and SpineUniverse.com.

Post-op AP x-ray:  after surgery to address adjacent segment diseaseFigure 5. Image courtesy of Paul C. McCormick, MD, and SpineUniverse.com.


The patient is now 6 months post-operative, and clinically, the patient has done fine.  There is resolution of myelopathy.

Concerns with the approach in addressing the recurrent myelopathy in 2012: 

  • The low-profile interbody devices don’t give you a lot of surface for bone grafting.  Make sure you augment the cage with enough bone graft so that the fusion can occur.
  • Sagittal alignment is slightly kyphotic at the C4-C5 level.  One of the concerns is that post-operative suboptimal sagittal alignment may be a potential risk factor for future adjacent segment disease at the rostral level (C3-C4).

Case Discussion

This case demonstrates a common scenario in cervical spondylosis. A middle aged male presents with myelopathy secondary to a disc herniation at C5-C6 with underlying spondylosis at C6-C7 in the presence of a congenitally narrow canal. Initial surgical treatment was well addressed anteriorly with a C6 corpectomy with other viable options of a two-level discectomy or a single-level C5-C6 discectomy. The patient had made an excellent recovery following the procedure however, presents 3 years later with a similar disc herniation proximal to the fusion.

Adjacent segment problems are a common phenomena following spinal fusions. Possible contributors to the proximal failure in this case include the persistent kyphosis that remains between C5 and C7, the proximal position of the anterior plate and the two-level fusion that exists between C5 and C7. There are various options available for treatment of this new disc herniation, which were delineated in the case. With the persistent kyphosis existing between the original construct, an opportunity presented with this new surgery to lengthen the anterior column and perhaps decrease the risk of a similar problem presenting at the next level. To achieve this, I feel removal of the previous plate and placement of a large lordotic-shaped structural graft, with a new plate either extending from C4-C5 or from C4 to C7 would have dealt with the two issues of adjacent segment disc herniation and focal cervical kyphosis.  A PEEK stand-alone device was used in this case that does not require removal of the plate. While this implant is lordotic in shape, and has been perfectly placed from a technical standpoint, it leaves minimal surface area for fusion and does not provide adequate lordosis to deal with the deformity in this case.

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