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.

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 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 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 4. Sagittal CT scan redemonstrating C3-C4 spondylolisthesis.

Diagnosis

C3-C4 spondylolisthesis and stenosis with myelopathy

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 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.

Figure 7. Lateral x-ray at 1 month postop

Figure 8. Anteroposterior x-ray at 1 month postop

Case Discussion

Ali A. Baaj, MD

Associate Professor of Neurological Surgery
Co-Director, Spinal Deformity and Scoliosis Program

Weill Cornell Medical College, Cornell University

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.