• HPI: The patient is a 57 year old male with roughly 10-years of progressively worsening neck and arm pain. On occasion, he will get shock-like sensations shooting down his spine to his sacrum with neck flexion. He reports decrease in right hand grip, noted when picking up objects. 

    PMH: Tinnitus, Chronic back pain, COPD 

    Social History: Lives on a farm. Is on disability for chronic back pain. Does not smoke or drink. 

    Family History: Noncontributory. 

    Exam: Limited range of motion in flexion, extension, and lateral bending of the neck. 4+ strength in left arm abduction, bilateral wrist extension, left hip flexion. Strength in other muscle groups is 5. Deep tendon reflexes: +2 biceps, +1 triceps, trace brachioradialis, +3 patellar. Other exam unremarkable. 

    Figure 1. Sagittal T2-weighted MRI demonstrating severe stenosis from C3/4 to C6/7 disc interspaces and kyphosis centered at C4/5. Note: trace intramedullary spinal cord hyperintensity from C4 to C6.

    Figure 2. Axial T2-weighted MRI demonstrating substantial central canal and neuroforaminal stenosis at C4/5

    Figure 3. Lateral x-rays of cervical spine in neutral (left), extension (center) and flexion (right) demonstrating cervical kyphosis centered at C4/5. No gross instability noted on flexion, extension views. Note: relative reduction of kyphosis in extensi

    1. Would you obtain any additional studies?

    2. If you elected to proceed with surgery, what would you perform?

    3. Which of the following describes you?

    4. I practice in one of the following locations.

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

    • this case witht CSM needs bidirectional approach 1)ant.cervical discectomy with interbody fusion 2)ant.plating 3)post.decompresive lamenectomy with lat.mass fixation
    • I might do ACDF C4/5-C6/7 and leave C3/4 alone but it would depend on how the axial views looked at that level which weren't provided. Earlier in my practice experience I would have gone posteriorly given the # of levels but as I've gained surgical experience, I now do 3 (and sometimes even 4) levels anteriorly and find better results...faster recovery, better deformity correction, better decompression of foramina, etc.
    • Modest kyphosis, of this magnitude, not a contraindication to posterior surgery. Effective foramenotomies better accomplished from posteriorly. Laminectomy of this many levels in the presence of kyphosis threatens worse instability. Laminoplasty
    • reimage in 3 mon and possible post
    • ACDF C4-5, C5-6,C6-7/ not including C3-4
    • I would perform 3 level ACDF then reevaluate, let fuse, POSSIBLE laminectomy later
    • I would favor corpectomies C4, C5&C6 with fibulae allograft & plating C3-C7.
    • reimage in 3 mon and possible post
    • Needs a C5 and C6 vertebrectomy, anterior plating and graft from C4-7 followed by C3-7 laminectomy, posterior instrumentation.
    • I might do an corpectomy of C5, ACD C6-7, plate stabilization C4-7, then follow him clinically, with option of posterior decompression and fusion later if he continues to have problems.
    • Laminectomy or laminoplasty will not take care of the anterior cord compresion or the kyphosis.
    • I would be sure to perform the surgery with the cervical spine in extention ie. posterior decompression and fusion with instrumentation.
    • a corpectomy of C4 would be an option.
    • I am surprised that his hand strength is normal given his history. Was a detailed hand exam done? CTS is always a possibility with decreased hand strength, but this can often be differentiated by a good history and good physical exam. If there were suspicion that the hand strength were due to CTS, then I would get NCVs prior to an operation. I still think he needs a cervical procedure, but if he has CTS as well, the hand may not get better and this is nice to know before cervical surgery.
    • I would do a CT without myelography. It gives good anatomical detail about the extent of the foraminal stenosis. I would offer surgery because he is already developing progressive problems. Posterior surgery does not address the kyphosis, nor the anterior compression, nor easily address the foraminal stenosis. Anterior surgery has to include C3/4, which is where all his movement is occurring, and without surgery will degenerate and eventually sublux, with further compression. I would also include a plate. If restoring sagittal balance is essential, which it may not be, he would need posterior facetectomies and a lateral mass fusion in addition to anterior surgery - so I might at least consider a combined approach. However, his posture in extension is not unreasonable, and therefore anterior fusion with a lordotic plate I think would be enough.
    • I would do CT-myelogram & pending results possibly change which cervical procedure I select. #c & d might be good considerations as well but won't take care of the ventral canal impingement. Another option could be vertebrectomy C4 thruC6 with strut + plate; possibly combined with posterior stabilization as in "d" CT-Myelo wopuld help me decide which option I discussed above to select.
    • there is significant kyphosis and therefore posterior approaches are unlikely to benefit. corpectomy c4,5,and C6 with bone fraft/cage and anterior plating is another option.
    • Ct to rule out opll, if present would changebsurgical plan
    • I'll do a C4 and C5 corpectomy with plating then followed by a laminoplasty C3-C7
    • I would do the anterior, and then determine if posterior was needed in a staged procedure.
    • I will not do the c3-4 ant. Cervical discectomy
    • Too many fusions in options. I did not see and appropriate option such as c4-5 and fusion and aggressive neck strenghtning.
    • Advise anterior corpectomy with bone graft.
    • I would favor a multilevel corpectomy and non-instrumented strut graft with or without a posterior stabilization.
    • I'd do C4 to C6 corpectomy and C3 to C7 fixation using a mesh cage with artificial bone granules, and anterior cervical plate.
    • doing only one procedure will not stabilize the spine
    • I would need a CT scan axial sections from C3-C7, with 2-d reconstruction to rule out posteriorly placed osteophytes impinging in to spinal canal. sandeep mohindra
    • worthwhile to consider an anterior decompression at C4 C5 level.
    • i practice in alabama
    • As the patient has neurological deficit I would go for anterior discoidectomy + fusion either with cage or the bone graft
    • would treat only the symptomatic lesion,determined by clinical exam in association with ncv/emg.I believe on current evidence this to be C4/5 ,C5/6 and C6/7.Laminectomy unlikel;y to succeed given reversed lordosis.So initial op will be disc removal and fusion with plate at above levels
    • The patient will have better cervical lordosis with C3-4 ACDF in addition to C3-7 laminectomy and C3-C7 lateral mass/T1 pedicle screw fusion. Restoring cervical lordosis is an important component for treating multi-level cervical sponylotic myelopathy.
    • My state, AL, is not listed.
    • the myelomalacia changes suggest to the possibility of lack of improvement, or slowness in improvement.
    • interesting case, The surgery is only to prevent further deterioration, any improvement in neurological symptoms is a Bonus. Postoperative Flex and extension X- ray any instability of worsening kyphosis, plan posterior pedicular screw fixation with reduction
    • Consider somatectomy half C4+C5+ Half C6
    • Consider somatectomy of half/C4+C5+half/C6
    • Besides the surgical option D,Iwould like to perform foraminotomy on the right side at c5/c6 and c6/c7 levels in addittion.
    • keep simple things simple
    • May also need posterior approach
    • c3-4 is the mobile segment going in to kyphosis will do C3-4 ACDF and c3 to c7 laminoplasty with lateral mass screw fixation in lordosis as he has some sighns of post colum involvement due to secondary stenosis and there is fixwd lordosis c4- to c7 at the same sitting
    • Would do the posterior decompression first..Wait for recovery..then do the anterior decompression and fusion/plating
    • I would do a ACDF at C45 and C56
    • Would use anterior plate for the fusion
    • This multilevel cervical spondylosis with kyphotic deformity can be managed by laminectomy with lateral mass fusion .
    • If non-smoker, then dense cancallous allograft with Ant-Cer dynamic plate. If smoker, then iliac crest autograft.
    • I think that the correction of the spine deformity is necessary because it is caused by the cervical spine degenerative disorder, so first we must correct the cervical spine stenosis and second the deformity with posterior stabilization to prevent further instability. Before the intervention we must have EMG and SSEP diagnostics to determine the severity of radiculopathy and possible mielopathy by mine consideration.
    • There is more that one way to handle this case
    • I will perform anterior discectomy and placement of PEEK cages no plating
    • I will perform anterior discectomy and placement of PEEK cages no plating
    • My procedure of choice would likely be a laminectomy C3-7, combined with a selective foraminotomy/partial medial facetectomy addressing the foraminal stenosis/-es.
    • Aditionally, securing the anterior fusion with a convenient plate.
    • He appears to be most symptomatic from the compression at C4/5 and the kyphosis appears to be centered at C3/4 on his flexion plain x-ray views. I would perform an ACDF @ 3/4 and C4/5.
    • Because the pathology is multisegmental ,symptomatology predominantly of posterior column and assosiated co-morbidity in form of COPD is present laminectomy seems to be better option but presence of kyphosis is making me wary for that i think doing fixation by lateral mass screw and rod will solve the problem . Inspite of all of these ,I will explain the patient that he may not improve after surgery because of presence of multisegmental hyperintensity changes of cord .
    • retired20 yrs. ago
    • I am going to operate inmediatelly, altougth with more studies I just have more documentation on the case, but practically he needs descompresive laminectomy plus fixation with pediacular screws. In a contry without money we have to do things less expensives,and more efective.
    • These are always difficult situations. I would favor a multilevel ACDF as a first procedure and follow the patient closely post-operatively. If he does well, I would not do any further intervention. If he continues to have problems, I would re-study him and possibly consider a posterior procedure such as a multi-level lami fusion with instrumentation.
    • Would consider 2 level vertebrectomy 1 level acdf c6-c7
    • Check after anterior surgery. May need post surgery as well
    • I think these case might need a posteriorr aproach but first i made a multiple level cervical discectomy and fusion
    • Prefer three level ACDF C4/5 to C6/7 Might need posterior fusion at a later date
    • I would want to have a complete evaluation of upper extremity function to serve as an objective observation. This could then be followed post operatively to evaluate return. Therefore I would do an EMG before going ahead with surgery.
    • I would do anterior vertebrectomy and fusion c4-c6 ( fusion c3 c7) and posterior approach ,lateral mass fusion c3 c7. In the same time. I would not consider laminoplasty because of the kyphosis.
    • Multilevel decompression an fusion with screws have better results
    • I would get a plain CT also, the patient might require a corpectomy depending upon extent of bone removal also if sagittal balance could not be restored or bone is soft they might also require posterior augmentation.
    • The case is not simple one. I think laminecotommine with laterl mass fixaction will be right procedure for this patient.
    • The case is not simple one. I think laminecotommine with laterl mass fixaction will be right procedure for this patient.
    • lack of cervical lordosis exclude the laminoplasty, and since he has compression from both anterior and posterior with 3 levels involved i would prefer the posterior decompression and fusion since it achieves both goals safely c/w the anterior approach.
    • It will be good if we get to read the discussion.
    • The case is not simple one. I think laminecotommine with laterl mass fixaction will be right procedure for this patient.
    • c4-5 corpectomy c6-7 acdf combined with c3-7 lateral mass screws

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