Cervical Spondylosis\Surgery\Worsening Symptoms

Female, 34 years old Orthopedic outpatient record: shoulder pain, numbness in the right arm, restricted neck movement, positive Spurling test. The following is the MRI report. Department: Orthopedic Ward Imaging date: March 29, 11:24 Report date: March 29, 11:58 Review date: March 29, 13:37 Image series: 1 Clinical diagnosis: Examination name: Cervical spine Imaging findings: Cervical alignment normal, physiological curvature straightened, vertebral body bone signal normal, all intervertebral discs showing short T2 signal changes, C5-6 intervertebral disc with central posterior protrusion, C6-7 intervertebral disc bulging, compressing the dural sac and nerve roots, spinal canal anteroposterior diameter not narrowed, bilateral lateral recesses narrowed. Cervical spinal cord signal normal, ligamentum flavum not thickened. Imaging diagnosis: 1. C5-6 intervertebral disc degeneration with posterior protrusion. 2. C6-7 intervertebral disc degeneration with bulging.

The following is the admission record. Department: Orthopedics Admission date: March 27 Record date: March 27 History provided by: the patient herself Attending physician diagnosis within 48 hours: cervical spondylosis Diagnosis date: March 27 Attending physician signature: (omitted) Chief complaint: Neck and shoulder pain for three years, worsening with right upper limb pain and numbness for over one month. History of present illness: Three years ago the patient developed neck and shoulder pain and discomfort without obvious cause. Symptoms recurred repeatedly afterward. An MRI (now lost) showed C5-6 disc degeneration and protrusion compressing the spinal cord. She visited our hospital’s specialist clinic where surgery was recommended, but the patient declined and pursued conservative treatment with self-medication. Symptoms continued to recur. One month ago her neck and shoulder pain worsened along with right upper limb pain, numbness, and weakness. An X-ray at another hospital showed C6 instability and sharpening of the uncovertebral joints. She then presented to our outpatient clinic and was admitted for further evaluation and treatment under the diagnosis of “cervical spondylosis.” Since onset she denies fever or weight loss. On admission she was alert, in good general condition, with normal bowel and bladder function and good appetite.

The following is the operative record. Surgery date: March 31, 9:00–10:10 am Preoperative diagnosis: cervical spondylosis Postoperative diagnosis: cervical spondylosis Pathology submitted: no Surgical classification: Class 1 Procedure: Anterior cervical C6 subtotal corpectomy with decompression, titanium mesh reconstruction, titanium plate internal fixation, and C3-4 cage placement with bone graft fusion Surgeon: (omitted) Assistant: (omitted) Anesthesiologist: (omitted) Scrub nurse: (omitted) Surgical steps: General anesthesia induced uneventfully. Patient positioned supine with thin pillow under shoulders and back, neck slightly extended. Standard iodine and alcohol skin preparation and draping. Right transverse anterior cervical incision approximately 6 cm. Skin and subcutaneous tissue divided, platysma transected, dissection between carotid sheath and visceral sheath to expose anterior C5 vertebral body. Prevertebral fascia incised and C6 vertebral body confirmed by fluoroscopy. Subtotal C6 corpectomy performed with decompression of C5-6 and C6-7 discs. Lower C5 and upper C7 endplates preserved. Intraoperatively, C5-6 and C6-7 disc herniations with surrounding osteophytes were seen compressing the spinal cord. Cancellous bone fragments from decompression were packed into a 10 mm diameter × 22 mm titanium mesh and placed into the decompression defect. A 37.5 mm Zephir titanium plate was fixed near the lower C5 and upper C7 endplates with four 13 mm screws. C3-4 decompression performed and a 12 mm wide × 5 mm thick cage inserted. Fluoroscopy confirmed satisfactory position. Hemostasis achieved, negative-pressure drain placed, wound closed in layers. Procedure completed. Anesthesia satisfactory, blood loss approximately 100 ml, no transfusion. On emergence from anesthesia, four-limb movement and sensation same as preoperative status. Internal fixation devices were the Zephir titanium plate and mesh system from Sofamor and the Solis interbody fusion cage from Stryker. Date: March 31 ********* The following is the discharge summary. Department: Orthopedics Admission date: March 27 Discharge date: April 8 Outpatient diagnosis: cervical spondylosis Admission diagnosis: cervical spondylosis Discharge diagnosis: cervical spondylosis Main symptoms and signs on admission: Neck and shoulder pain for three years, worsening with right upper limb pain and numbness for over one month. Cervical physiological curvature present (as in original), right Hoffmann sign (+-), diminished right biceps reflex, normal bilateral triceps and brachioradialis reflexes, decreased pinprick sensation in right upper limb, decreased pinprick sensation on lateral right calf and dorsum of foot. Bilateral knee reflexes normal. Main laboratory results: March 28 blood and urine routines basically normal, hepatitis B surface antigen (-), hepatitis C antibody (-), liver and kidney function and blood glucose basically normal. Special examinations and important consultations (with dates and report numbers): March 28 electrocardiogram: normal. March 29 cervical MRI: cervical degenerative changes, C3-4, C5-6, C6-7 disc degeneration with posterior protrusion. April 3 cervical AP and lateral radiographs: internal fixation in satisfactory position. Clinical course and treatment outcome (procedure name, surgery date, transfusion volume, resuscitation): After admission, investigations showed no clear surgical contraindications. On March 31 under general anesthesia the patient underwent anterior cervical C3-4 discectomy with interbody cage placement, C6 subtotal corpectomy, titanium mesh reconstruction, and titanium plate internal fixation. Surgery was uneventful. Postoperative anti-inflammatory treatment given for infection prevention. Follow-up cervical X-rays showed good implant position and secure fixation. Recovery satisfactory and patient discharged. Complications: none Condition at discharge (symptoms and signs): General condition good, reports pain at back of neck, no other specific complaints. Physical examination: alert, breathing unlabored. Neck wound: Grade I/healed by primary intention, sutures removed. Good movement and sensation in both upper limbs, good peripheral circulation. Post-discharge medications and advice: 1. Active functional exercises; wear cervical collar during activity for three months. 2. Outpatient follow-up. 3. Indomethacin, 3 boxes, 1 capsule orally three times daily. Treatment outcome: cured April 8

Postoperative patient complaints: Original symptoms not only failed to improve but many new discomforts appeared. Head and neck feel stiff and cannot turn at all. I never had headaches before, but now my head hurts. Numbness was only in a few fingers of the right hand, now both hands are completely numb. The whole shoulder and back feel heavy, as if carrying dozens of pounds of rice all day. Chest also feels tight constantly. The following is the MRI report Department: Orthopedic Ward Imaging Date: March 29, 11:24 Report Date: March 29, 11:58 Review Date: March 29, 13:37 Image Series: 1 Clinical Diagnosis: Examination Name: Cervical Spine Imaging Findings: Normal cervical alignment, straightening of physiological curvature, no abnormal bone signal in vertebral bodies, short T2 signal changes in all intervertebral discs, central posterior protrusion of C5-6 intervertebral disc, bulging of C6-7 intervertebral disc compressing the dural sac and nerve roots, no narrowing of the anteroposterior diameter of the spinal canal, narrowing of bilateral lateral recesses. No abnormal signal in the cervical spinal cord, no thickening of the ligamentum flavum. Imaging Diagnosis: 1. C5-6 intervertebral disc degeneration with posterior herniation. 2. C6-7 intervertebral disc degeneration with bulging.

The following is the admission record Department: Orthopedics Admission Date: March 27 Record Date: March 27 History provided by: the patient herself Attending physician diagnosis within 48 hours: cervical spondylosis Diagnosis Date: March 27 Attending Physician Signature: (omitted) Chief Complaint: Neck and shoulder pain for three years, worsening with right upper limb pain and numbness for over one month. History of Present Illness: Three years ago, the patient developed neck and shoulder pain and discomfort without obvious cause. It recurred repeatedly afterward. An MRI (now lost) showed C5-6 disc degeneration and herniation with spinal cord compression. She visited the hospital's specialist clinic where surgery was recommended, but the patient declined and opted for conservative treatment including self-medication. Symptoms continued to recur. One month ago, neck and shoulder pain worsened along with right upper limb pain, numbness, and weakness. An X-ray at another hospital showed C6 instability and sharpening of the uncovertebral joints. She then presented to our outpatient clinic and was admitted for further management under the diagnosis of "cervical spondylosis." Since onset, she denies fever or weight loss. On admission, she was alert, in good general condition, with normal bowel and bladder function and good appetite.

The following is the operative record Surgery Date: March 31, 9:00-10:10 am Preoperative Diagnosis: Cervical spondylosis Postoperative Diagnosis: Cervical spondylosis Pathology Submitted: No Surgical Classification: Class 1 Procedure: Anterior cervical C6 subtotal corpectomy with decompression, titanium mesh reconstruction, titanium plate internal fixation, and C3-4 cage placement with bone graft fusion Surgeon: (omitted) Assistant: (omitted) Anesthesiologist: (omitted) Scrub Nurse: (omitted) Surgical Steps: General anesthesia was successfully induced. The patient was positioned supine with a thin pillow under the shoulders and back, neck slightly extended. Standard iodine and alcohol skin preparation and draping. A right transverse anterior cervical incision approximately 6 cm long was made. Skin and subcutaneous tissue were incised, the platysma was divided, and dissection proceeded between the vascular sheath and visceral sheath to expose the anterior aspect of the C5 vertebral body. The prevertebral fascia was incised and C6 was confirmed by fluoroscopy. Subtotal corpectomy of C6 was performed along with removal and decompression of the C6/7 and C5/6 discs. The inferior endplate of C5 and superior endplate of C7 were preserved. Intraoperatively, disc herniations at C5-6 and C6-7 with surrounding osteophytes were seen compressing the spinal cord. Cancellous bone fragments from decompression were packed into a 10 mm diameter × 22 mm length titanium mesh and placed into the decompression trough. A 37.5 mm Zephir titanium plate was fixed with four 13 mm screws near the inferior endplate of C5 and superior endplate of C7. Decompression was performed at C3-4 with insertion of a 12 mm wide × 5 mm thick cage. Fluoroscopy confirmed satisfactory position. Hemostasis was achieved, a negative-pressure drain placed, and the wound closed in layers. The procedure ended. Anesthesia was satisfactory, blood loss approximately 100 ml, no transfusion required. On awakening, limb movement and sensation were unchanged from preoperative status. Internal fixation devices were the Zephir titanium plate and mesh system from Sofamor and the Solis interbody fusion cage from Stryker. Date: March 31 ********* The following is the discharge summary Department: Orthopedics Admission Date: March 27 Discharge Date: April 8 Outpatient Diagnosis: Cervical spondylosis Admission Diagnosis: Cervical spondylosis Discharge Diagnosis: Cervical spondylosis Main Symptoms and Signs on Admission: Neck and shoulder pain for three years, worsening with right upper limb pain and numbness for over one month. Cervical physiological curvature present (as in original), right Hoffmann sign (+-), diminished right biceps reflex, normal bilateral triceps and brachioradialis reflexes, decreased pinprick sensation in right upper limb, decreased pinprick sensation on lateral right calf and dorsum of foot. Normal bilateral knee reflexes. Main Laboratory Results: March 28 blood and urine routine basically normal, hepatitis B surface antigen (-), hepatitis C antibody (-), liver and kidney function and blood glucose basically normal. Special Examinations and Important Consultations (with dates and report numbers): March 28 ECG: normal. March 29 Cervical MRI: cervical degenerative changes, C3-4, C5-6, C6-7 disc degeneration with posterior protrusion. April 3 Cervical AP and lateral X-rays: satisfactory internal fixation position. Clinical Course and Treatment Outcome (including procedure name, surgery date, transfusion volume, and resuscitation details): After admission, no obvious surgical contraindications were found. On March 31 under general anesthesia, anterior cervical C3-4 discectomy with interbody fusion cage, C6 subtotal corpectomy with titanium mesh reconstruction and titanium plate internal fixation were performed. Surgery was uneventful, with routine postoperative anti-inflammatory therapy to prevent infection. Follow-up cervical X-rays showed good implant position and secure fixation. Recovery was satisfactory and discharge was approved. Complications: None Condition at Discharge (Symptoms and Signs): General condition good, with neck pain at the back, no other specific complaints. Physical Examination: Alert, normal respiration. Neck Wound: Grade I / healed by primary intention, sutures removed. Good movement and sensation in both upper limbs, good peripheral circulation. Post-Discharge Medications and Recommendations: 1. Active functional exercises, wear cervical collar during activities for three months 2. Outpatient follow-up 3. Indomethacin * 3 boxes, 1 capsule orally three times daily Treatment Outcome: Cured April 8

Postoperative patient complaints: The original symptoms not only failed to improve but many new discomforts appeared. The head and neck felt stiff and could not turn at all. I never had headaches before, but now my head hurts. Originally only a few fingers of the right hand were numb, now both hands are completely numb. The entire shoulder and back feel heavy, as if carrying dozens of pounds of rice all day. The chest also feels tight constantly.