History & Physical:This is a 43-year-old patient who presented with a four to five year history of progressive bilateral upper extremity paresthesias and weakness, more so on the left than the right. He notes he had fallen out of a tree as a child, and was told he had a problem with the C2 vertebra but not treated. An MRI scan was obtained revealing an os odontoideum with a significant pannus formation, contributing to spinal cord compression with evidence of cord contusion and signal changes (Figure 1). Evidence of ligamentous instability is noted as well on dynamic x-rays (Figure 2). He denied any current bowel or bladder changes, nor other motor or sensory changes.
On physical examination, this patient was seated in no acute distress. His vital signs were a blood pressure of 122/60, pulse of 76, and respirations of 16. His gait is within normal limits without evidence of antalgic or Trendelenburg components. Range of motion was diminished in flexion, extension, and lateral bending, but full in rotation. Spurling's maneuver was negative bilaterally, with negative Lhermitte's but sensations of “shocks” in extension. Motor examination revealed strength of 4-/5 diffusely in his left upper extremity with 5/5 elsewhere. Sensory examination was intact light touch and pinprick, with diminished vibration in his left hemibody. Deep tendon reflexes were brisk bilaterally with 3+ at the biceps, brachioradialis, and triceps. Hoffman's reflex is noted bilaterally, with an exaggerated response on the left hand side. Three beats of clonus is evident on the left hand side.
Figure 1A. MRI Scan.
Figure 1B. MRI Scan.
Figure 1C. MRI Scan.
Figure 1D. MRI Scan.
Figure 2A. Flexion-Extension X-Rays.
Figure 2B. Flexion-Extension X-Rays.
1. The treatment option of choice in this patient is:
2. The timing of surgical intervention would be:
3. The pre-operative treatment of this patient would be:
4. The use of steroids is indicated in this patient:
5. The optimal surgical approach for decompression would be:
6. The optimal surgical approach for stabilization would be:
7. The instrumentation used for the surgical construct for this patient would be:
8. The orthosis offered to this patient would be:
9. Please add any suggestions or comments regarding this case:
There is an emergency after this patient has seen in the clinic. The patient needs cervical intervention (decompression and fusion) as soon as possible.
We know preoperatively that the patient has a reducible abnormality, which is expected to correct with cervical traction, the need for transoral decompression is therefore not mandatory.
Anterior transoral decompressoin with posterior fusion with rod and wire and followed by stabilisation with halo brace would suffice.
Also would put the patient on the latest treatment for Rheumatoid Athritis
I would perform C1-2 Transarticular screw fixation with posterior Gallie fusion. There is CSF behind the cord and the pannus will regress once stabilised