February 2018

A 65-Year-Old Man With Rapidly Progressive Quadriparesis

History & Exam

History
 
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. 
 
Exam
 
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.
6. Comments
7. Which of the following is an indication for a combined circumferential cervical fusion.

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.

References

  • Jeyamohan SB et al. Effect of steroid use in anterior cervical discectomy and fusion: a randomized controlled trial. J Neurosurg Spine. 2015 Aug;23(2):137-43. 
  • Kim SD et al. Independent predictors of failure of nonoperative management of spinal epidural abscesses. Spine J. 2014 Aug 1;14(8):1673-9.
  • Curylo LJ, Mason HC, Bohlman HH, Yoo JU. Tortuous course of the vertebral artery and anterior cervical decompression: A cadaveric and clinical case study. Spine (Phila Pa 1976) 2000;25:2860–4.
  • Cheung JPY, Luk KD-K. Complications of Anterior and Posterior Cervical Spine Surgery. Asian Spine Journal. 2016;10(2):385-400. 
  • Dagirmanjian A, Schils J, McHenry M, Modic MT . MR imaging of vertebral osteomyelitis revisited. AJR. December 1996, Volume 167, Number 6
  • König, S.A. & Spetzger, U. Surgical management of cervical spondylotic myelopathy - indications for anterior, posterior or combined procedures for decompression and stabilization. Acta Neurochir (2014) 156: 253.
  • Fehlings MG, Smith JS, Kopjar B, et al. Perioperative and delayed complications associated with the surgical treatment of cervical spondylotic myelopathy based on 302 patients from the AOSpine North America Cervical Spondylotic Myelopathy Study. J Neurosurg Spine. 2012;16:425–432.
  • Leven D, Cho SK. Pseudarthrosis of the Cervical Spine: Risk Factors, Diagnosis and Management. Asian Spine Journal. 2016;10(4):776-786.