Foreign Diplomat with Neck Pain and Right C6 and C7 Radiculopathies

History

A 59-year-old male who is a foreign diplomat presents with neck pain and right C6 and C7 radiculopathies.

Examination

The patient has a wide based gait and poor tandem gait.

3+ reflexes, + Hoffman’s and Babinski’s signs

Prior Treatment

The patient has failed physical therapy and epidural steroid injections.

Pre-treatment Images

 Figure 1: Sagittal MRI showing bulges at C2-C3, C3-C4, and C5-C6. Image courtesy of Richard G. Fessler, MD, and SpineUniverse.com.

Figures 2-4 are axial MRIs of C3-C4 (Figure 2), C5-C6 (Figure 3), and C6-C7 (Figure 4).

Figure 2. Image courtesy of Richard G. Fessler, MD, and SpineUniverse.com.

Figure 3. Image courtesy of Richard G. Fessler, MD, and SpineUniverse.com.

Figure 4. Image courtesy of Richard G. Fessler, MD, and SpineUniverse.com.

Diagnosis

Central canal stenosis at C3-C4 and right foraminal disc herniations at C5-C6 and C6-C7

Selected Treatment

MIS decompression was done at C3-C4, and MIS foraminotomies were done on the right side at C5-C6 and C6-C7.

Outcome

The patient had an excellent outcome.

Case Discussion

K. Daniel Riew, MD

Professor of Orthopedic Surgery

Columbia University Medical Center

This is a 59-year-old patient with congenital spinal stenosis with myelo-radiculopathy. The central stenosis causing myelopathy at C3-C4 appears to be due to three factors: congenital stenosis, small disc protrusion and, probably most importantly, ligamentum flavum buckling, which is worse on the left than on the right.

The patient also has cord signal change at C3-C4. C4-C5 appears to be normal and C5-C6 and C6-7 have foraminal disc herniations, causing C6 and C7 radiculopathies, respectively.

He was treated with minimally invasive decompressions as outlined above. Such decompressions can effectively treat such patients. One small concern that I have has to do with the longevity of such decompression. Given that the patient is 59 years old and has congenital spinal stenosis, there is the possibility that sometime in the future, he might develop stenosis at the remaining levels in his cervical spine, other than C3-C4. Had he had a C3 laminectomy, laminaplasty of C4, C5, C6 and undercutting C7, with posterior foraminotomy and discectomies, it is possible that he might be fixed for life. On the other hand, such an operation is no doubt more invasive than the one that was chosen. When confronted with such a dilemma, I believe it is best to include the patient in the decision-making process by informing them of all of the pros and cons of each procedure.