Case Study: Reduced Range of Motion
Dr. Peter Hollis
The patient, an 82-year-old male, came to us for a neurosurgical evaluation after having noted a relatively rapid deterioration in his ability to walk. Once a vigorous hiker, he had been diagnosed by his primary physician with peripheral neuropathy, balance issues, and neck stiffness. He also has some claudication type symptoms with significant back pain radiating into the lower extremities when he walked or stood for even brief periods. Earlier EMG and nerve conduction studies showed findings compatible with peripheral neuropathy and possible multilevel lumbar radiculopathy. Imaging studies of the lumbar spine showed spondylolisthesis with profound stenosis at L3-4 moderating somewhat above and below. Degenerative spondylosis was identified as the precipitating factor.
Upon examination at Cushing Neuroscience Institute we noted a markedly reduced range of motion in the neck specific to extension and right rotation. Patient’s reflexes were depressed throughout and his plantar reflexes were mute as well. We recommended an MRI of the cervical spine to investigate possible cervical spondylitic myelopathy as an additional pathology. When the MRI report came back it revealed severe cervical stenosis at C4-5 and C5-6 with disk osteophytes causing spinal cord compression. It was then determined through discussions with surgeons and patient that surgery to correct this condition should take precedence over the lumbar issues. A week later J.S. underwent surgery for spinal cord compression in the cervical spine.
The patient was given general anesthesia and his motor and sensory EPs set up for monitoring. He was positioned with head, neck, and body all in a neutral position on a doughnut pillow so that the anterior aspect of his neck was accessible. Using C-arm intraoperative imaging guidance, the surgeon made an incision just above the C5 vertebral body to permit exposure of the cervical spine from the midline to the medial border of the sternocleidomastoid muscle on the left side. The associated muscles were retracted and the C4-5 disk was completely removed giving access to a broad-based osteophyte projecting from the inferior aspect of C4. This bony projection was also drilled down to a thin residual ledge and removed, along with a ligament across the back of the disk space. With total neural decompression achieved at this site, an appropriately sized ROI-C® interbody prosthesis filled with demineralized bone matrix was tamped into place and locking plates applied to complete segmental fixation.
A similar discectomy, osteophyte/ligament removal and decompression were then carried out at C5-6, with the same corrective results. Throughout the procedure the patient remained stable with no change in EP potentials and minimal firing from the EMG.
At the patient’s request the lumbar correction was postponed for a year, at which time the patient returned to have his L2-5 spinal stenosis with degenerative scoliosis and nerve root impingement surgically relieved. Given general anesthesia and with routine EP monitoring devices in place, the patient was placed on his right side and further positioned so that when viewed intraoperatively on the C-arm the critical areas were precisely visible and in symmetrical position. Small skin incisions were made above the left iliac crest to access L3-5 and L2-3, after which dilators were placed under continuous EMG stimulation to open up and navigate safe passage through the layers of muscle to the disk spaces. Discectomies and insertion of appropriate PEEK interbody prostheses filled with demineralized cell matrix were sequentially performed at L4-5 and at L3-4. With these interventions the patient’s lateral scoliosis and spondylolisthesis were observed to be markedly improved. The remodeling also permitted safe access to the L2-3 level, allowing the surgical team to complete a third diskectomy and interbody arthrodesis at L2-3.
The patient tolerated the procedure well and eight weeks later the patient was pain free and back at work.