SpineUniverse Case Study Library

Cervical Deformity and Myelopathy in an Elderly Female

History

The patient is a 76-year-old female with a history of progressive cervical pain with numbness, tingling and clumsiness of her upper extremities. She has no previous history of neck-related problems and is a nonsmoker.

Examination

The patient's examination was positive for hyperreflexia, bilateral Hoffman’s sign, and Lhermitte’s sign.

Pretreatment Imaging

Cervical deformity, myelopathy, pre-operative sagittal MRIFigure 1. Pre-operative MRI

Cervical deformity, myelopathy, pre-operative flexion x-rayFigure 2. Pre-operative flexion x-ray

Cervical deformity, myelopathy, pre-operative extension x-rayFigure 3. Pre-operative extension x-ray

Diagnosis

Cervical deformity (listhesis), myelopathy

Suggest Treatment

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Selected Treatment

The patient underwent an anterior cervical discectomy and fusion with instrumentation at C3-C6. The plate was attached to C3 and C6 with C4 and C5 vertebrae lagged to the plate to restore listhesis.

She was then positioned prone and a C3-C6 laminectomy, fusion and lateral mass instrumentation was performed.

Cervical deformity, myelopathy post-op x-rayFigure 4. Post-operative x-ray

Outcome

  • The patient's symptoms related to myelopathy immediately improved following surgery.
  • She was placed in a hard collar for 6 weeks with an external bone growth stimulator to promote spinal fusion.
  • Within 6 months, post-operative x-rays demonstrated anterior solid fusion.
  • At 6 months, the patient returned to playing golf.

Cervical deformity and myelopathy, 6 months post-op x-ray, solid fusionFigure 5. Post-operative x-ray demonstrates solid cervical fusion.

Authors' Case Discussion

Given our concern for osteoporosis, we selected the anterior-posterior option to buttress instrumentation and decrease the risk for pseudoarthrosis.

Locking the top and bottom vertebrae to the plate followed by reducing the middle subluxed vertebral segments allowed for an excellent correction of the cervical deformity.

The post-operative MRI demonstrates the degree of ventral decompression and ligamentotaxis, which coupled with the decompressive laminectomy reconstitutes the canal to a great degree.

Peer Case Discussion

In this case, a 76-year-old woman presented with symptoms and signs of cervical myelopathy. Her imaging was notable for a degenerative cervical spine, which is the most likely cause of her presentation, that being C3-C4 stenosis and spondylolisthesis. Her surgeons elected to perform a front-back procedure consisting of a C3-C4, C4-C5, C5-C6 anterior cervical discectomy and fusion (ACDF) with a C3-C6 laminectomy and posterior instrumented fusion. Her post-operative clinical and radiographic outcomes are excellent.

While the authors are commended for their outstanding result, I would argue that the patient (a 76-year-old woman) underwent an excessive amount of surgery. Her primary issue is at C3-C4, and it is likely that a C3-C4 ACDF (or, at most, a C4 corpectomy) would have resulted in the same clinical outcome. Then, she would have undergone just 1-2 hours of surgery instead of approximately 5-6 hours, with a shorter hospital length of stay, less post-operative pain, and higher fusion rates.

Authors' Response to Case Discussion

We appreciate Dr. Than’s thoughtful commentary on this complex case. There are certainly multiple options for treating cervical spondylotic myelopathy, and the addition of deformity and instability to the equation further complicates the decision-making algorithm. While we do seek to minimize surgical procedures to the smallest possible, there are reasons why we felt an anterior-only procedure (and certainly a C3-C4 ACDF) would fail to achieve a successful outcome for this patient:

1) The patient displayed significant abnormalities in both local and regional alignment. C3-C4 demonstrated a 4-mm listhesis that increased to 6-mm on flexion. C4-C5 demonstrated a 4-mm listhesis that resolved to normal alignment on extension. Both these parameters demonstrate significant instability at the C3-C4 and C4-C5 levels. C2-C7 sagittal vertical axis was +2.5-cm, and cervical kyphosis between C2 and C7 was +12-degrees. These all demonstrate instability and deformity, which increase the risk of pseudoarthrosis and hardware failure and are associated with poor long-term clinical outcomes.

2) The patient was a thin, post-menopausal white female; epidemiologically at risk for osteoporosis. This furthered our impetus for posterior instrumentation given the risk for pseudoarthrosis and hardware failure.

We agree that adding a posterior component to the procedure does add marginally to operative time, hospital length of stay and immediate post-operative pain. However, the addition of posterior instrumentation does, in fact, INCREASE fusion rates compared with isolated anterior fusion procedures. This is especially important to consider in patients with higher risks for pseudoarthrosis: patients with diabetes or osteoporosis, those undergoing multi-level procedures, those undergoing deformity corrections putting more strain on hardware (risks of which the patient had multiple). Should this patient have gone on to hardware failure and pseudoarthrosis, the litany of potential complications associated with revision anterior cervical exposure and hardware removal and long-segment posterior cervico-thoracic instrumentation and fusion put the chosen operative strategy in some perspective.

Community Case Discussion (1 comment)

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


I agree we all of you that you have to take into account a lot of comorbidities, patient´s age, etc.
In my country another not less important issue are the costs.
Could you please tell me Dr. Wind, how much could it be the cost for a surgery like this one you´ve performed?
How much are the costs of implants?
Thank you very much!

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