Radiology Teaching Files > Case 3098801

Contributed by: Fritsch & Thompson.
Patient: 67 year old female
History: This 67 yr. old female presented with history of numbness/tingling in left upper extremity, several weeks duration. Recent investigations for this complaint included an EKG and NCV studies. More recent onset of urinary urgency, bilateral aching pain in the lower extremities and "loss of control" of the right leg prompted consultation with another physician who ordered MRI examination, images of which are shown here.

Fig. 1

Fig. 2: Although not definitive, the AP diameter is below 12mm and suggests stenosis

Fig. 3

Fig. 4

Fig. 5

Fig. 6: T1 sagittal image showing large disc herniation with cord compression

Fig. 7: T2 sagittal shows higher signal in cord at level of large HNP

Fig. 8: Axial T1 C5-C6 level

Fig. 9: Axial T1 C6 level

Fig. 10: Axial T1 C6

Fig. 11: Axial GRE c5-C6 level

Fig. 12: Axial GRE at C5-C6 level

Fig. 13: Axial GRE at C6 level

X-rays show marked degenerative changes scattered throughout the cervical spine with degenerative spondylolilsthesis at C4-5 and C5-6. Plain film evaluation demonstrates
IVF narrowing and suggests central stenosis (AP canal diameter approx. 11mm). MRI evaluation demonstrates disc herniation with central encroachment, deformity of the cord and high cord signal at C5-6 compatible with myelomalacia.

Diagnosis: Large disc extrusion creating stenosis and severe spinal cord compression with myelomalacia.
Discussion: Central canal stenosis is a common sequelae of advanced degenerative joint disease, with or without disc herniation. Degenerative intersegmental displacment (degenerative spondylolisthesis) contributes to other causes of neural encroachment, including thickening of the ligamentum flavum and vertebral spondylosis.

Ref. physician:  Loan Khuu, DC

Case Of the Week: 10/27/2005

MRI Case of the Week: 7/5/06

The history suggests significant myelopathy that is at risk for neurological worsening. Surgical approaches, though varied, should ultimately address the ventral compression first, at the C6 C7 levels. A simple decompressive diskectomy may not adequately decompress the caudal and rostral extension of the lesion. Thus, anterior corpectomies, partial or total, may be needed, followed by C5 to T1 strut graft fusion and intrumentation. The stenosis at the higher cervical levels, in particular, C2/3 may pose a significant problem as well. Addressing the span of C2/3 all the way to C7/T1 level via a single anterior approach is not reasonable, nor safe,in this elderly 64 year old patient. Risks of laryngeal injury, post operative hematoma, and dysphagia are high if attempted. Thus, a staged decompression is the most reasonable approach. Firstly, address the major compression at the lower cervical spinal levels via an anterior approach. Subsequently, one can address the multiple level degenerative spinal stenosis via a posterior multi level laminectomy. (Strictly speaking, a stand-alone laminectomy--without the anterior approach--would be dangerous for neurological worsening post-operatively because of the spondylolisthesis and the loss of normal lordosis.) Peter J. Yeh, MD Bellaire, TX--Peter Yeh, 2005-10-28
Additional Details:

Case Number: 3098801Last Updated: 06-23-2006
Anatomy: Spine and Peripheral Nervous System   Pathology: Other
Modality: Conventional Radiograph, MRExam Date: Access Level: Readable by all users
Keywords: myelomalacia; stenosis; cervical spine

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