Cervical Myelopathy: Progressive Problems with Balance and Handwriting
History
This 54-year old male has a prior history of a herniated disc at C5-C6. He had an anterior cervical discectomy and fusion (ACDF) performed 8 years ago for arm pain and radiculopathy. He did well for many years following that surgery. In the past 8 months, the patient has had progressive problems with balance and handwriting. He has also had clumsiness with his hands. However, he has no arm pain, neck pain, or discomfort in his neck.
Examination
On examination, the patient is unable to do a tandem walk without losing his balance. He has 3+ increased reflexes throughout his upper and lower extremities with bilateral Hoffmann’s reflexes in both hands. His motor strength and sensory exam are normal throughout.
Prior Treatment
As mentioned above, the patient had ACDF at C5-C6 8 years ago. He did very well for many years but over the past 8 months had started developing the symptoms stated above. He tried some physical therapy, but this did not help.
Pre-treatment Images
Diagnosis
The patient was diagnosed with adjacent segment disease and cervical stenosis leading to cervical myelopathy.
Suggest Treatment
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The patient had a cervical laminaplasty because cervical stenosis and myelopathy were present above and below the prior fusion from C3-C4 all the way down to C7-T1. Although he had multiple level involvement, he did not have symptoms of neck pain.
There was some lordosis present, which allowed for a posterior approach for decompression, and since there were no signs of instability on flexion/extension radiographs (not shown), a fusion was not necessary.
Post-treatment Images
Outcome
It has been 2 years after the patient’s surgery, and he has recovered significantly. He no longer has balance issues or clumsiness. He is still slightly hyper-reflexic but much less so compared to his previous surgery.
Case Discussion
This relatively young patient presents with myelopathy and no evidence of radiculopathy. He has no neck pain and some preservation of lordosis. It is assumed he still has some motion, although this is not mentioned in the clinical presentation provided. Given this scenario, laminoplasty is the most reasonable treatment option. The surgery was performed well and the result was good at last follow up.
What if the presenting picture was different? There are a number of issues that would alter the decision-making process.
If the patient had significant neck pain in the absence of radiographic evidence of instability or facet disease, laminoplasty is probably still the best first option. If there was a single-level radiculopathy in association with the myelopathy, then a properly focused foraminotomy with laminoplasty should be effective.
The situation changes if there were multi-level radiculopathies, particularly if they were bilateral, and this patient has shown a tendency toward disc degeneration. The value of foraminotomy decreases with the severity of disease and particularly the number of levels requiring treatment. Multi-level radiculopathy in the settling of myelopathy is usually better addressed with anterior decompressions and fusions at C3-C4,C4-C5, C6-C7, and C7-T1, depending on the level of clinically significant radiculopathy. If all segments required treatment, I would favor backing up the construct with posterior fixation. Anterior approaches allow for excellent canal decompression and direct and indirect foraminal decompression.
Finally, the preservation of at least some lordosis is critical. Without lordosis, the ability to adequately decompress the spinal cord via a posterior route is markedly diminished when there is anterior canal compromise. If the spine was straight or kyphotic, then the anterior-posterior decompression fusion would be mandatory.
Community Case Discussion (2 comments)
This is patient should do well with a less invasive tubular posterior decompression without fusion. In the absence of neck pain, segmental instability, Modic changes and or fixed flexion deformity a less morbid procedure should be offered to the patient. Our experience with 16 mm tubular decompression over multiple levels has not resulted in increased neck pain or instability. Bilateral decompression via unilateral approach in this case would be an outpatient procedure worhty of discussion.
I would get a cervical CT the MRI IS SUGGESTIVE OF SEGMENTAL OPLL. IF NO OPLL WOULD DO FROM THE FRONT. IF EXTENSIVE OPLL WOULD DO LAMI WITH PROBABLE FUSION
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