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Cervical Disk Hernia_3

Short summary

62-year-old male with extremity radiculopathy and weakness in intrinsic muscles. His diagnosis include stenosis (cervical spine C3-C7), rediculitis, degenerative disc disease and cervical spondylosis with possible myelopathy. Given the patient's age and the appearance of the MRI scan showing significant multilevel stenosis, the expert recommends surgical intervention.


Medical Background
HISTORY: 62 year old male with bilateral upper extremity radiculopathy, possible lower extremity radiculopathy, and no evidence of myelopathy. There is no mention as to whether the patient has normal fine motor function, including difficulty buttoning, using utensils, writing, opening objects. There is also no mention of problems with distance walking.
PHYSICAL EXAMINATION: The physical examination reveals weakness in intrinsic muscles of the right hand and is otherwise normal, including no evidence of myelopathy. 
DIAGNOSTIC STUDIES: A CT scan of the cervical spine, dated August 2007, was reviewed. There appears to be loss of cervical lordosis with evidence of multilevel degenerative changes. There appears to be central stenosis at multiple levels. Also noted is anterior bridging osteophytes fusing C4-C6 and C6-C7
An MRI of the cervical spine, dated January 2008 was also reviewed. There is central stenosis noted from C3-C7. This is most significant at C3-4 on the sagittal images. The axial images also reveal multiple levels of central and bilateral stenosis. At C3-4 this is a herniated disc which results in very severe central stenosis and bilateral foraminal stenosis. At C4-5 there is severe central stenosis and left greater than right bilateral foraminal stenosis. At C5-6 there is moderate central stenosis and left greater than right bilateral foraminal stenosis. At C6-7 there is moderate to severe central stenosis and bilateral foraminal stenosis. Again there appears to be loss of normal cervical lordosis with the spine in neutral to slight kyphosis. There is no evidence of cord edema, signal change, or myelomalacia. 
An EMG report, dated January 2008, was reviewed. The report reads, “signs of severe chronic neuropathy in the patient’s muscles whose roots are C5-6 on the right.”
Medical opinion

IMPRESSION:   62 year old male with bilateral upper extremity radiculopathy, no evidence of myelopathy, and MRI consistent with multilevel cervical stenosis.
PLAN: The patient’s complaints are centered around bilateral upper extremity radiculitis with possible evidence of possible myelopathy suggested by hand intrinsic weakness. A more detailed history would help further clarify this point. 
Given his age, and the appearance of the MRI scan showing significant multilevel stenosis, surgical intervention is a reasonable option. While the patient may choose to consider physical therapy, medications, and injections to help with the radicular pain, given the severe stenosis, he will likely, eventually and invariably, require surgery. I would recommend surgical intervention since the patient’s health will only decline with age, making surgical intervention more risky then. 
In terms of surgical intervention, the goals are cervical spine decompression and stabilization. The specific approach may be done in one of three ways. From the back, from the front, from the front and then from the back. 
With respect to the posterior approach, a decompression, decompression and fusion without instrumentation, or a decompression and posterior spinal fusion with lateral mass screw instrumentation may be done from C3-7. 
With respect to the anterior approach, a multilevel anterior cervical discectomy and fusion with plate and screw instrumentation may be considered from C3-4, C4-5, C5-6, C6-7.
 Finally, a combined approach may also be performed. An anterior approach mentioned above followed by a posterior fusion with or without instrumentation may be done. This may be done in 1 operative day or staged. 
Given the CT scan revealing significant anterior fusion with bridging osteophytes, an anterior approach would be fairly extensive, both in terms of decompression and fusion as well as soft tissue retraction. 
A posterior decompression with or without fusion with or without instrumentation would be reasonable, since the patient is in neutral position and his cord will likely float back and become decompressed. The patient is not in significant kyphosis as to risk cord tenting anteriorly and not becoming decompressed. Furthermore, given the anteriorly fused osteophytes, continued progressive kyphosis will likely not happen in this adult.
Therefore, I would recommend a posterior decompression without fusion from C3-7. If there is no improvement, then an anterior multilevel C3-4, C4-5, C5-6, C6-7 may be considered. Again, the surgery may be approached from a variety of ways, and surgeon preference should play some role in the decision-making process.