SpineUniverse Case Study Library

Cervical Spondylolisthesis and Stenosis With Myelopathy

History

A 53-year-old man with a history of schizophrenia, manic depression, hepatitis C, prostate cancer, diabetes, use of cigarettes and methamphetamine, and alcohol abuse presented to the emergency room with a chief complaint of progressive weakness over the past few months; especially over the past one month. Four months previously, he fell in a bathtub while smoking methamphetamine and lost consciousness. Although he awoke without any symptoms, he began experiencing pain and increasing weakness over the next few weeks. Previously, he had fallen due to inability to control his lower extremities. He also complained of difficulty using his hands. At presentation, he noted 48-hours of fecal (but not urinary) incontinence.

Examination

Table 1 (below), reviews the patients upper extremity motor responses.

Upper extremity examination detail

Lower extremities: Full strength

  • Rectal tone intact

Sensation: Decreased proprioception in the bilateral upper extremities; could not differentiate between sharp and dull on the right.

Reflexes: Normal

Pretreatment Imaging

Figure 1. Sagittal MRI T2 STIR sequence demonstrating C3-C4 spondylolisthesis, stenosis secondary to disc herniation and ligamenFigure 1. Sagittal MRI T2 STIR sequence demonstrating C3-C4 spondylolisthesis, stenosis secondary to disc herniation and ligamentum flavum hypertrophy, and spinal cord signal change.

Figure 2. Axial MRI T2 STIR sequence demonstrating severe C3-C4 stenosis with spinal cord signal change.Figure 2. Axial MRI T2 STIR sequence demonstrating severe C3-C4 stenosis with spinal cord signal change.

Figure 3A. Sagittal CT scan demonstrating no facet dislocation on either the right or the left.Figure 3A. Sagittal CT scan demonstrating no facet dislocation on either the right or the left.

Figure 3B. Sagittal CT scan demonstrating no facet dislocation on either the right or the left.Figure 3B. Sagittal CT scan demonstrating no facet dislocation on either the right or the left.

Figure 4. Sagittal CT scan redemonstrating C3-C4 spondylolisthesis.Figure 4. Sagittal CT scan redemonstrating C3-C4 spondylolisthesis.

 

Diagnosis

C3-C4 spondylolisthesis and stenosis with myelopathy

Suggest Treatment

Indicate how you would treat this patient by completing the following brief survey. Your response will be added to our survey results below.

Selected Treatment

C3-C4 anterior cervical discectomy and fusion (ACDF). Post-operative imaging below.

Figure 5. Lateral x-ray demonstrating C3-C4 ACDF, with incomplete reduction of spondylolisthesis.Figure 5. Lateral x-ray demonstrating C3-C4 ACDF, with incomplete reduction of spondylolisthesis.

Figure 6. Anteroposterior x-ray demonstrating C3-C4 ACDF.Figure 6. Anteroposterior x-ray demonstrating C3-C4 ACDF.

Outcome

Immediately after surgery, the patient was of full strength in his upper extremities. By post-operative day (POD) 2, he noted that his walking was improved. He was discharged to a skilled nursing facility on POD 2.

At his first post-operative visit one month after surgery (Figures 7, 8), the patient continued to have full strength in all upper and lower extremity muscle groups. Subjectively, he denied any neck or extremity pain, and he stated that his strength and walking had all improved.

lateral x-ray one month postop following anterior cervical discectomy and fusionFigure 7. Lateral x-ray at 1 month postop

anteroposterior x-ray one month postop following anterior cervical discectomy and fusionFigure 8. Anteroposterior x-ray at 1 month postop

Case Discussion

Dr. Than presents a case of a patient with challenging psychosocial background and severe, symptomatic cervical stenosis and myelopathy. The pre-operative imaging demonstrate a degenerative spondylolisthesis with severe stenosis and cord signal change at the C3-C4 level. The selected treatment was a standard anterior cervical discectomy and fusion (ACDF), and the short-term clinical outcome appears satisfactory.

Though a 1-level ACDF procedure is generally considered routine and low-risk, there are several key issues that need careful consideration in the management of high-risk patients. These include: potentially higher pseudoarthrosis rate, wound infection, choice of biologic, and postoperative patient compliance.

Overall, Dr. Than achieved excellent short-terms results and is commended for tackling this challenging case.

Community Case Discussion (3 comments)

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


this is an interesting case with a good short term results. I believe the present symptoms are mainly related to C3-4 level but, considering stenosis and degenerative changes in C5-6 and 6-7 I think doing a posterior C3 to C7 laminectomy and instrumented fusion would be another treatment option in this case. so I recommend following the case.
Good luck

Consider posterior fixation as anterior fusion is somewhat tenuous mechanically and pt is at higher risk for nonunion and hardware failure.

Although the patient do well, ACDF (without correcting subluxation) does not make sense in such a situation.
After such a fixation, the cord seems still compressed between the C3 lamina and the posterior-superior corner of the C4 body.
C3 laminectomy + C3-C4 lateral mass fixation should be selected treatment in that patient.

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