C4-C7 Spondylosis with Foraminal Stenosis

History

The patient is 58-year-old female. She's right-hand dominant. She presented with a one-year history of progressively worsening right-sided neck and arm pain. The pain radiates down her right arm in a C6 dermatomal distribution. She has associated paresthesias in her thumb and index finger.

Examination

The patient is 5’5” and weighs 130 pounds. She has limited range of motion with extension and right lateral bending/rotation. She has a positive Spurling’s test to the right side.

Manual motor testing: 4/5 right bicep, tricep, and wrist extension/wrist flexion.

The patient has decreased sensation in a right C6 dermatomal distribution.

She has VAS scores of 8/10 for the right arm and 3/10 for the neck.

Prior Treatment

The patient has tried oral medications, physical therapy, and epidural steroid injections (ESIs). A right C5-C6 transforaminal ESI resulted in notable relief of right arm pain during the anesthetic phase.

Pre-treatment Images

 Figure 1: Patient-submitted pain diagram showing right arm pain, as well as right-sided neck pain

Figure 2: AP x-ray (left) and lateral x-ray (right)

Figure 3: Right oblique x-ray showing right C4-C5, C5-C6, C6-C7

Figure 4: Sagittal (left) and right sagittal CTs showing foraminal stenosis

Figure 5: MRIs demonstrating foraminal stenosis at C4-C5 (left), C5-C6 (middle), and C6-C7 (right) 

Diagnosis

The patient was diagnosed with C4-C7 spondylosis with foraminal stenosis.

Selected Treatment

The patient had MIS C4-C7 laminoforaminotomies.

Intraoperative Images

Figure 6: Intraoperative targeting at C5-C6

Figure 7: MIS laminoforaminotomies were done through a 1.5 cm posterior incision.

Figure 8: Intraoperative decompression showing C6 nerve root

Outcome

The patient reported relief of her neck and arm pain

Case Discussion

This patient presents with a C6 radiculopathy recalcitrant to non-operative management. Imaging studies demonstrate substantial degenerative disease, regional kyphosis, and multilevel foraminal stenosis.

In treating this patient, the key issue is to determine what is causing her symptoms. Given the classic C6 radiculopathy presentation and response to nerve root block, a C5-C6 MIS foraminotomy would be a viable option.

In the setting of myelopathy or debilitating neck pain, consideration of a more aggressive multilevel reconstructive procedure would be reasonable. Since this patient did not have myelopathy or debilitating neck pain, then a focal decompression without destabilizing the spine makes sense.