Patient is a 60-year-old female who presents with severe right upper extremity pain and weakness over several months.
She had a prior C6-7 ACDF with plate and subsequently developed next segment degeneration at C5-6 which resulted in a second ACDF at C5-6 with removal of the prior C6-7 plate.
Current imaging studies (Figs. 1 and 2) demonstrated significant degenerative collapse of C45 segment, retrolisthesis and with severe right foraminal stenosis as well as C3-4 degenerative disc degeneration with moderate compression of thecal sac. Patient failed conservative management and it was decided, given her prior two anterior procedures, that an excellent decompression could be accomplished with a posterior laminectomy, foraminotomy and fusion to maintain alignment.
(Fig. 1) Sagittal T2 cervical MRI demonstrates significant C34 and C45 disc degeneration and osteophyte formation and instability status post anterior cervical discectomy and fusion C5-C7.
(Fig. 2) Axial T2 cervical MRI at C4-5 demonstrating significant osteophytic disease with bilateral neural foraminal compression of the C5 nerve roots, right greater than left.
A C2 to C6 posterior cervical laminectomy was conducted as well as a C3-C6 fusion with instrumentation. Most importantly an extensive foraminotomy was performed of the right C5 nerve root, which was followed laterally with a Kerrison punch.
Anteriorly to the C45 facet joint the right C5 nerve root was found in a more superior position under the C4 inferior process. The method of a posterior foraminotomy allowed an extensive decompression of the nerve root which would not have been as well accomplished with an anterior approach.
Given the prior two anterior surgeries, the patient had a reasonable lordosis, and the primary pathology was foraminal stenosis, it was of our opinion that a posterior approach was a better choice than an anterior approach.
(Fig. 3) AP and Lateral cervical X-ray 6 months from surgery demonstrates a stable construct and alignment.
Postoperatively the patient had an uneventful course with relief of her right arm pain and stable construct (Fig. 3) at follow up at 6 months.
References:
Kong, L, Cao, Jumming, Wang, Lingeng et al (2016). Prevalence of adjacent segment disease following cervical spine surgery: A PRISMA-compliant systematic review and meta-analysis. Medicine, 95(27), e4171. Doi: 10.1097.