• HPI: 72 year old man presents with 1 year h/o of progressive weakness in his arms > legs. Symptoms have been more bothersome over the past 6 weeks with some intermittent neck pain. He is s/p left BKA secondary to an embolism many years ago. No hx of trauma or previous spine surgery. He is currently in a skilled nursing facility for physical therapy due to his progressive symptoms (he lived independently until about 1 month ago). He denies any bladder or bowel incontinence. He has fallen about 4 times in the past 6 months. 

    PMH: 
    1. Hypertension 
    2. Diabetes 

    Family Hx: 
    Son is healthy. All other relatives are deceased (no remarkable history). 

    Medications: 
    1. Aspirin 
    2. Multivitamin 

    Social History: 
    Retired from the US Postal Service. He lived independently alone at home until about 1 month ago when he was forced by his son to move to a nursing home for physical therapy. 

    Neurological Exam: 
    General Appearance: Well nourished, well developed, with no apparent distress and moderately obese 
    Muscle Bulk: Normal and symmetrical in the upper & lower extremities. 
    Motor:

    Deltoid: Right 3, Left 3 
    Elbow flexors: Right 4, Left 4 
    Wrist extensors: Right 5, Left 5 
    Elbow extensors: Right 4, Left 4 
    Finger flexors: Right 5, Left 5 
    Hip flexors: Right 4, Left 4 
    Sensory: Normal

    Proprioception: normal 
    Gait: Not tested , s/p BKA and currently in wheelchair 
    Reflexes: 3+ UE 
    Long Tract Signs: Hoffman positive bilaterally 

    Figure 1. CT cervical spine: sagitall reconstruction demonstrates degenerative changes throughout with multiple levels of cervical fusion and listhesis. No MRI available.

    1. What is your recommendation to this patient?

    2. What approach do you select?

    3. You choose to operative from a posterior approach alone. Which levels do you include in your decompression and/or fusion?

    4. You choose to operative from an anterior approach alone. Do you choose to perform:

    5. Do you perform his surgery with intra-operative neuromonitoring?

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

    • needs mri cervical spine
    • I would base my operative decision making in large part on flex/ext films not presented here. I would also like to see the axial images. Why is there no MRI?
    • Would need to evaluate flexion and extension films as well as axial images, MRI would be nice
    • there is a good case for non operative mgt given a wheelchair existence in any case and the morbidity associated with age and the likelihood that his pain can be managed with medication.
    • I shall get the MRI Cervical spine and decide after that, won't operate without a MRI
    • I would obtain C-spine MRI pre-op
    • I would not do any surgery without a prior MRI.
    • I would request MRI before surgery. Why it was not done? Clinical presentation did not mention upper motorneuron lesion signs in low extremities. Are they negative? I think its noncomplete information for further decisions.
    • Is very importan in this patient the surgery, because is the only form tha dissapaer his symptoms
    • i would order for an MR scan before contemplating on any surgery. From the available CT images there is no significant cord compression. therefore non operative management would suffice.
    • the patient should complete the management by physiotherapy ,tonics

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