February 2018

A 65-Year-Old Man With Rapidly Progressive Quadriparesis

History & Exam

A 65-year-old male presents with a rapidly progressive history of triceps, hands and lower extremity weakness. His hands have progressively lost strength and he has been non-ambulatory over the past day. He was recently admitted with fevers and a diagnosis of pneumonia and bacteremia. His remote history is notable for an esophageal achalasia, esophageal perforation, esophagectomy and gastric pull-up surgery. 
Afebrile and normotensive. Tachycardia HR 100.  Malnourished.
No scars on anterior or posterior neck. Healed scar over abdomen and lower chest.  
Positive sagittal balance with cervical kyphosis. Neck and back are not tender. Reduced range of motion neck.
Negative Spurling’s sign. Positive Lhermitte's sign
Cranial nerves II-XII are intact
DTRs – 3+ upper extremities, 3+ lower extremities
Strength- 5/5 Deltoid and biceps; 4/5 Triceps; 3/5 wrist extensors/flexors; 3/5 hand intrinsics
4+/5 bilateral lower extremities
+ Clonus bilateral lower extremities, Positive Hoffman’s sign bilateral, Positive bilateral Babinski Sign.
Slightly decreased pinprick sensation from upper chest down
Spastic gait

Upright Radiographs

Upright Radiographs

Magnetic Resonance Imaging

Magnetic Resonance Imaging

Magnetic Resonance Imaging

Magnetic Resonance Imaging

1. Perioperative steroid use in anterior cervical discectomy and fusion procedures
2. Which of the following increases the likelihood that nonoperative management of spinal epidural abscesses will fail?
3. What is the incidence of abnormal vertebral artery location in the cervical spine?
4. Which of the following describes you?
5. I practice in one of the following locations.
7. Which of the following is an indication for a combined circumferential cervical fusion.

Your answers will be added to those already obtained and tabulated at the end of the month.

Case Explanation: 

The imaging in this case is suggestive of an an epidural abscess with a significant solid phlegmon component spanning from C5/6 to C7/T1. It superimposed on a C5/6 herniated disc leading to mass effect on the cord which displays T2 signal. 

Question 1: The correct answer is delays time to fusion. Perioperative steroids do significantly delay time to fusion due to anti-inflammatory mechanisms. Steroids do not reduce the risk of infection. Steroids increases risk of perioperative hyperglycemia but improves dysphagia symptoms.

Question 2:  The correct answer is diabetes. Spinal epidural abscesses treated with medical management alone has a high risk for failure if the patient is diabetic. Other risk factors include age > 65, methicillin resistant staphyloncus aureus  infection, or neurologic compromise. Sex and serum leukocyte count are not predictive of nonoperative treatment failure.

Question 3: The correct answer is 2.7%. The incidence of abnormal vertebral artery location was found to be 2.7% in cadaveric studies.

Question 7: The correct answer is cervical kyphosis. Relative indications for circumferential approach to decompress and stabilize the cervical spine include cervical  kyphosis due to biomechanical loads. Other indications include but are not limited multi-level anterior corpectomy, poor bone quality, metabolic disorders, and poor nutritional state. Predominantly posterior compression supports posterior surgery. Single level corpectomies may not require posterior stabilization. Advanced age is not an indication for circumferential surgery.


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