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.

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