• HPI: 35 y/o male presents to a local ER after collapsing while trying to stand from the breakfast table that morning. He initially complains of left leg weakness, and while awaiting L-spine MRI, develops left arm weakness. 

    ROS: He admits to intermittent hand clumsiness over the past 3 months (difficulty buttoning shirt, dropping objects, etc). Denies any bowel/bladder dysfunction. 

    PMH: History of transient paralysis as a child from which he fully recovered. 

    Social Hx: Auto mechanic. No tobacco or illicit drug use. Social alcohol use. 

    PE:

    No neck tenderness
    Motor:
      LUE: 3/5 proximal, 4-/5 distal LLE: 4/5 throughout
      RUE: 5/5 RUE: 5/5
    Sensory: decreased sensation to light-touch & pin-prick in LUE & LLE.
    Reflexes: 3+ throughout Toes upgoing bilaterally


    Figure 7 & 8 (Below)
     Patient underwent traction and subsequent trans-oral approach with odontoid resection and posterior O-C fusion. His sensorimotor symptoms improved after Physical Therapy. 

    Figure 1. An MRI of the C-spine is completed

    Figure 2. An MRI of the C-spine is completed

    Figure 3. An MRI of the C-spine is completed

    Figure 4. Cervical spine CT imaging

    Figure 5. Cervical spine CT imaging

    Figure 6. Cervical spine CT imaging

    Figure 7.

    Figure 8.

    1. Which imaging modality would you obtain first?

    2. What’s the most likely diagnosis?

    3. What is your next step in treatment for this patient?

    4. If you were to offer surgery would you ustilize intraopertaive moitoring?

    5. Please add any suggestions or comments regarding this case:

    Very interesting case. It clearly demostrated advantage for combined approach, wich i totally agreed.                  

    I think the diagnosis is:basilar invagination+Arnold-Chiari malformation .OPérative surgery is best treatment( young patient).           

    I would try to reduce him in traction. Then perform a transoral resection of the odontoid followed by occiput to C2 fusion.           

    5 questions and we know about cvj anomaliy          

    fantastic case!!            

    no need to detailed comment the case is very clear that needs decompression of lower brainstem by resecting odontoid and stabilising occipitocervical region.           

    While anterior approach directly addresses the problem, posterior approach is one with which all neurosurgeons are very familiar. Placing the patient in traction followed by occipito-cervical decompression (converting upper c-spine into a trough) and fusion may be equally reasonable. It avoids the potential complications of the trans-oral route and even with 12 weeks of Halo vest post-op. (for enhancing the possibility of fusion) may be more tolerable to the patient. A delayed anterior approach can still be considered, if optimal results are not achieved by posterior approach alone.

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