Case Report: Cervical Spinal Stenosis (Dr Stephens)

This is a 49-year-old female who presented to our clinic with chief complaints of difficulty with gait, bilateral upper extremity weakness and numbness. Symptom duration was approximately four months. She had recently undergone a carpal tunnel release one month prior to my seeing her for carpal tunnel syndrome as an etiology of her right hand numbness. She saw no improvement from this procedure. Prior to her onset of symptoms she was very active. At the time of presentation, she had great difficulty ambulating even short distances. Physical examination revealed a positive Lhermitte's sign. She exhibited diffuse, global upper extremity weakness. Her gait was very uncoordinated and spastic. She had sustained clonus of her right lower extremity and 3 beats of clonus on the left. She had a positive Babinski's sign on the right. Hoffman's reflex was positive bilaterally in her upper extremities.

Differential diagnosis at that time was amyotrophic lateral sclerosis, multiple sclerosis, spinal neoplasm and cervical myelopathy.

MRI scan was obtained of her cervical and thoracic spine. This revealed severe cervical spinal stenosis with a marked narrowing of the cervical spinal canal from C4 to C7, with substantial signal change within the spinal cord. Final diagnosis was cervical spondylotic myelopathy.

She underwent a two level anterior cervical corpectomy with fibular allograft strutting and anterior plating shortly after diagnosis was made. She had no perioperative complications and was discharged home on her second post-operative day.

At three month surgical follow up, her gait was found to be markedly improved to the point that she was able to resume exercise and walk three-fourths a mile per day. While her gait had clinically improved, she still had overt signs of spasticity upon clinical examination. She continued to have bilateral clonus worse on the right. Upper extremity strength returned to normal bilaterally. Upper extremity sensation was also noted to improve but not completely return to normal at three-month follow up.

Cervical spondylotic myelo-pathy is very responsive to surgical intervention, particularly if caught in the early stages. This patient had more advanced myelopathy and, therefore, I would not expect a full return of normal neurologic function. Long-term clinical follow up series show that the great majority of these patients will improve and that the surgery almost universally arrests the progression of the myelopathy. The key to successful treatment remains early diagnosis and intervention.

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Figure 1. Axial MRI sections from the C4-C5, C5-C6, C6-C7 interspace revealing severe acquired cervical stenosis.

Figure 2. Saggital MRI revealing cervical spinal stenosis from C4 to C7 and the marked signal change within the spinal cord.

 

Figure 3. Lateral post-operative x-ray showing the fibular strut graft in position with an anterior cervical plate.

 

 

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Last Updated: 10/4/03