Spinal Cord Compression in a Young Man

Spinal Cord Compression in a Young Man

Dr. Nitin Bhatia

History

A 38-year-old right hand dominant European man was referred for evaluation of left arm pain, numbness, tingling, and slight subjective weakness. Upon evaluation, he noted a five month history of pain extending from his shoulder down the lateral aspect of his left arm to the his thumb and index finger.  He also complained of numbness and tingling in his left thumb and index finger.  Upon questioning, he did note mild loss of fine motor function in both hands, but no balance, bowel, or bladder abnormalities.  His past medical history was significant for congenital cardiac disease with a history of surgical transposition of the great vessels and current moderate cardiac myopathy.

Physical exam:

He was found to have 5/5 strength with manual motor testing in all muscle groups except for his left bicep, which was graded 4/5.  He was hyperreflexic in his bilateral brachioradialis and throughout his bilateral lower extremities.  He had slight ataxia and positive Hoffman’s sign bilaterally.  Sensation was slightly decreased in his left C6 dermatome.

Imaging studies:

  • Plain radiographs of the cervical spine showed straightening of cervical lordosis and moderate degenerative disc disease (DDD) from C5-C7 (Fig. 1).
  • MRI scan without contrast showed severe spinal stenosis, primarily from C5-7, with associated spinal cord compression and cord signal change.       The posterior longitudinal ligament (PLL) appeared thickened from C5-C7. (Figs. 2a and 2b)
  • CT scan without contrast showed the aforementioned DDD as well as ossification of the PLL (OPLL) from C5-C7 with central bony stenosis (Figs. 3a and 3b).
Lateral plain radiograph of the cervical spine showing loss of lordosis and DDD primarily from C5-C7.
Fig. 1
MRI Scan, sagittal view, at C6-7: Severe spinal stenosis from C5-7 with spinal cord compression and cord signal change. Note the thickened appearand of the OPLL from C5-C7.
Fig. 2a
MRI Scan, axial view at C6-7: Severe spinal stenosis from C5-7 with spinal cord compression and cord signal change. Note the thickened appearand of the OPLL from C5-C7.
Fig. 2b

 

CT scan, sagittal view at C6-7: DDD most significant at C5-7 with OPLL. Central bony stenosis from the OPLL can be appreciated on the axial view.
Fig. 3a
CT scan, axial view at C6-7: DDD most significant at C5-7 with OPLL. Central bony stenosis from the OPLL can be appreciated on the axial view.
Fig. 3b

Diagnosis:

Multilevel cervical spinal stenosis secondary to OPLL with myeloradiculopathy.

Surgical options:

The numerous options were discussed with the patient including anterior cervical corpectomy with fusion, posterior cervical laminoplasty, and posterior cervical laminectomy with instrumented fusion. Given the patient’s loss of lordosis and multilevel stenosis with OPLL, a posterior laminectomy from C4-T1 with instrumented fusion from C4-T2 was chosen. It was felt that this option may help avoid the complications of dural tear and cerebrospinal fluid (CSF) leak associated with anterior decompression in patients with OPLL. Additionally, given his loss of lordosis, it was felt that a posterior instrumented fusion was required to prevent further progression of cervical kyphosis. The patient agreed with the procedure and informed consent was obtained. The patient was optimized medically for surgery.

Surgery:

The patient was positioned in the prone position using Mayfield head tongs. His head was elevated to decrease intraoperative bleeding. A posterior midline approach to the cervical spinal was performed. Lateral mass screws were placed bilaterally from C4-C6, and pedicle screws were placed bilaterally at T1 and T2. No screws were placed at C7 to facilitate placement of the rods.

We now proceeded with a posterior cervical laminectomy from C4-T1 with foraminotomies at bilaterally at C4-5 and C5-6 to address the radiculopathy. There was excellent decompression of the spinal canal with posterior migration of the thecal sac. Appropriately sized and shaped rods were placed and set caps were placed and tightened. Cross-links were placed for both stability and protection of the spinal cord from the posterior musculature.  (Figs. 4a, 4b, 4c, 4d).

Post-operative images: a) Sagittal view CT scan showing placement of lateral mass screws from C4-C6 and pedicle screws at T1-T2.
Fig. 4a
Post-operative images: b) Axial view of the lateral mass screws.
Fig. 4b
Post-operative images: c) Axial view of the T2 pedicle screws.
Fig. 4c
Post-operative images: d) Axial view showing the laminectomy with overlying crosslink.
Fig. 4d

Local bone graft from the decompression was morcellized and combined with allograft demineralized bone putty.  This was placed over the decorticated posterior elements following resection of the facet capsules and debridement of the facet joints.

For pain management, liposomal bupivacaine was used to provide long acting local anesthetic relief. A deep drain and vancomycin powder was placed.  The incision was closed in multiple layers.

Post-operative course:

The patient was monitored on the telemetry unit due to his extensive cardiac history. He did well overall without cardiac complications and improvement of his preoperative symptoms.  His post-operative pain was well controlled with the liposomal bupivacaine and IV and oral narcotics for 72 hours.

Minimally Invasive Solutions for Neck Related Arm Pain in an Athletic Physician

Minimally Invasive Solutions for Neck Related Arm Pain in an Athletic Physician

Dr. Nitin Bhatia

History

This is a very pleasant 44-year-old right hand dominant male physician whose problems started approximately one to two years ago. They began with acute onset of right shoulder pain, followed by increased pain in the right side of the neck radiating down the arm into his fingers. This arm pain was associated with paresthesias and fluctuating weakness. At that time, he received two-three months of physical therapy with traction, which helped improve arm strength. However, he had recurrent episodes and flare-ups of severe right-sided neck pain accompanied by debilitating symptoms of pain radiating to the upper neck, right scapula, shoulder blade, forearm, then to his hand where he had numbness, tingling sensation, and weakness in the biceps and hand grip. He gradually lost motor strength in the right arm, which affects his ability to perform long radiology procedures. After working for two hours, he feels that the right arm is fatigued and weaker. He denies any balance problems and does not have similar symptoms on the left side. He reports a constant coldness in the right hand and rates his pain as being 8 on a scale of 1 to 10. The pain is directly related to activities. He continues to do cervical traction at home as he has his own cervical traction device. He has tried cervical epidural steroid injections that provide temporary and limited relief.

Physical exam showed a positive Spurling sign to the right with decreased right biceps reflex and 4/5 strength in the right biceps. Otherwise, his exam was normal.

Imaging studies showed degenerative disc disease at C5-6 with loss of disc height [Figure 1], and right sided C5-6 foraminal stenosis [Figure 2].

Preop lateral xray
Fig. 1
MRI axial C5-6
Fig. 2

Surgical Options

The numerous options were discussed with this knowledgeable patient. He chose to undergo surgical intervention due to his increasing symptoms and failure to respond to non-surgical treatment. The different options included anterior cervical discectomy and fusion of C5-6 versus cervical total disc arthroplasty versus posterior right C5-6 foraminotomy. The patient chose to undergo a minimally invasive foraminotomy.

Surgery

The patient was positioned in the prone position using Mayfield head tongs. His head was elevated to decrease intraoperative bleeding. A minimally invasive approach to the posterior cervical spine was performed using gradually larger tubular dilators. An appropriately sized working tube was placed and locked in position using a positioning arm attached to the OR table. The position of the tube was confirmed on multiple views of fluoroscopy [Figure 3A and 3B].

Intraop AP
Fig. 3A
Intraop lateral
Fig. 3B

The operating microscope was used for the remainder of the case. A right sided laminoforaminotomy was performed. Excellent improvement of the foraminal stenosis was achieved.

For pain management, oral Celebrex was used preoperatively. Liposomal bupivacaine was used to provide long acting local anesthetic relief.

Post-op

The patient reported immediate relief of his preoperative painful radiculopathy. He was discharged home within 24 hours of surgery. A cervical collar was provided for comfort, but the patient chose not to use it after 72 hours. For six weeks, pushing, pulling, and lifting were limited to 10 pounds. After the six week period, all restrictions were eliminated. Two weeks after surgery, the patient returned to work, including interventional radiology.

Figure Legend

Figure 1 - Preop lateral xray
Figure 2 - MRI axial C5-6
Figure 3a - Intraop AP
Figure 3b - Intraop lateral