This document describes the medical history, examination, investigations, diagnosis, and treatment for a 53-year-old female patient presenting with neck pain and left arm weakness. She reported a 6-month history of neck pain radiating to both shoulders and arms, as well as recent proximal and distal weakness in her left arm. Her examination found increased tone and 4/5 weakness in her left arm. Imaging including X-ray, MRI, and CT of the cervical spine showed disc issues, spondylosis, and possible tumor. Her final diagnosis was cervical myelopathy. Her treatment included admission, counseling, optimization, surgery involving anterior cervical discectomy and fusion at three levels as well as two-level corpectomy, post
2. History
53 year old female , married ,right handed , house wife
,resident of hyderabad with NKCM admitted through
opd with c/o:
Neck pain for 6months
Weakness of left arm since 2month
No hx of urinary incontinence , headache , dec vision ,
seizures ,speech difficulty , dec hearing
3. According to my pt she was alright 6 months back then she
developed neck pain which radiates to both shoulder ,left
arm as well as right hand .It is sudden ,gripping , moderate
to severe , intermittent , progressive . It relieves on
extension of neck and aggravates on flexion of neck.It has
no special time of occurrence and no relation with posture
and coughing.she has hx of weight lifting.It is associated
with numbness and tingling in both upper extremities.
She developed weakness of left arm 2 month back which is
in proximal as well as distal , gradural , mild ,
progressive.she can do routine activities with both
hands.She has loss of sensation in both arms but intact
sensation in perianus.she has no hx of fever , weight loss ,
night sweats , TB contact , trauma , DM & HTN.
4. She has no hx of urinary incontinence
She has no significant lobar , cranial , cerebellar ,
endocrine and systemic symptoms.
No significant past medical surgical hx , personal hx ,
family hx socioeconomic hx , drug hx, allergic hx
LEVEL : Cervical spine( myelopathy)
D/D :
Disc
Spondylosis
tumor
5. Examination
An old age pt , well dressed ,good looking ,well oriented
with time place and person with normal built and height
with following vitals and non vitals
Pulse : 78 bpm , BP : 120/80 mm hg , RR : 16 breaths/min ,
T: A/F
Pallorness , clubbing , koilynchia dehydration , cynosis ,
jaundice , lymphadenopathy , edema not present.
No buldge on scalp palpation and scar mark of Vp shunt
presnet on head
No thydroid swelling is palpated on deglutition
MME : 30/30
Primitive reflexs : absent
6. Upper limbs Lower limbs
Inspection : SWIFT : absent
Bulk : symmetrical
Tone : Inc in L elbow and
wrist while normal on right
Power : 4/5 below C4 on left
side while normal on right
Reflexes : +2
Hoffman : absent
Inspection : SWIFT : absent
Bulk : symmetrical
Tone : normal on both side
Power : 5/5 in all myotome
Reflexes : +2
Plantars : downgoing
7. Spine is non-tender , Lhermittes sign positive
Lobar , cranial , cerebellar and systemic signs are not
present
LEVEL : Cervical spine( myelopathy)
D/D :
Disc
Spondylosis
tumor
8. Investigations
Specific :
Xray cervical spine (AP XTSX CC)
MRI cervical spine
CT scan cervical spine
Routine :
CBC ,SUCE , PT/APTT/INR . Hep b & c . CXR
Relevant :
9.
10. Final diagnosis and management
Admission
Counselling
Optimization
Preop care
Surgery : ACDF(three level & two level corpectomy )
Postop care
Followup
Rehabilitation
Outcome
11. Surgery
Shifting : to ot after consent & counselling
Position : supine , neck extended, pressure points padded
Equipment : microscope , implant , c.arm , neuromonitoring , bipolar
Anesthesia : G/A
Level identification : c.arm
Incision : Transverse incision from midline to medial border of SCM at Ciricoid cartilage
level
Dissection: skin , platysma , deep cervical fascia ,muscles
Retraction : carotid sheath & SCM laterally , tracheoesophageal groove medially
Prevertebral fascia : dissected
Microscopic dissection
Disc identification : with needle of syringe
Discectomy : C4-5 ,C5-6,C6-7 levels after ALL disection with roungers
Corpectomy: C5 and C6
Decompression verification
Plate fixation
Wound closure
12. Complications
1. exposure injuries
a) perforation of viscus: ● pharynx● esophagus: ● trachea
b) vocal cord paresis:
c) vertebral artery injury:
d) carotid injury
e) CSF fistula
f) Horner’s syndrome
g) thoracic duct injury
h) thrombosis of internal jugular vein
2. spinal cord or nerve root injuries
a) spinal cord injury:
b) avoid hyperextension during intubation
c) bone graft must be shorter than interspace depth
d) sleep induced apnea
13. 3. bone fusion problems
a) failure of fusion
b) anterior angulation deformity
c) graft extrusion:
d) donor site complications: hematoma/seroma, infection, fracture of ilium, injury to
lateral femoral cutaneous nerve, persistent pain due to scar, bowel perforation
4. miscellaneous
a) wound infection
b) post-op hematoma:
c) dysphagia and hoarseness:
d) adjacent level degeneration
e) postoperative discomfort:
● globus
● nagging discomfort in neck
f) complex regional pain syndrome (CRPS)
g) angioedema
h) pneumothorax / hemothorax