Detailed Treatment Process
Female, 34 years old Orthopedic outpatient medical record: shoulder pain, numbness in the right arm, limited neck movement, positive Spurling test The following is the magnetic resonance imaging report Department: Orthopedic Ward Imaging Date: March 29 11:24 Report Date: March 29 11:58 Review Date: March 29 13:37 Image Sequence: 1 Clinical Diagnosis: Examination Name: Cervical Spine Imaging Findings: Cervical spine alignment normal, physiological curvature straightened, vertebral body bone signal no abnormality, all intervertebral discs show short T2 signal changes, C5-6 intervertebral disc protrudes backward centrally, C6-7 intervertebral disc bulges, compressing the dural sac and nerve roots, spinal canal anterior-posterior diameter no narrowing, bilateral lateral recesses narrowed. Cervical spinal cord signal no abnormality, ligamentum flavum no thickening. Imaging Diagnosis: 1. C5-6 intervertebral disc degeneration; posterior protrusion. 2. C6-7 intervertebral disc degeneration; bulging.
The following is the admission record Department: Orthopedics Admission Date: March 27 Record Date: March 27 History Provider: 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, aggravated with right upper limb pain and numbness for more than one month. History of Present Illness: Three years ago the patient developed neck and shoulder pain and discomfort without obvious inducement. It recurred repeatedly afterward. MRI (lost) showed: C5-6 intervertebral disc degeneration and protrusion, compressing the spinal cord. She visited our hospital expert outpatient clinic, surgery was recommended, the patient refused, and chose self-medication and other conservative treatments. It continued to recur afterward. One month ago, the patient's neck and shoulder pain and discomfort worsened and right upper limb pain, numbness and weakness appeared. X-ray at another hospital showed C6 cervical instability, sharpening of uncovertebral joints. She then came to our hospital outpatient clinic, for further diagnosis and treatment, admitted under "cervical spondylosis". Since onset, denied fever, weight loss history. After admission, clear consciousness, general condition good, bowel and bladder normal, appetite good.
The following is the surgical record Surgery Date March 31 9:00-10:10 am Preoperative Diagnosis: cervical spondylosis Postoperative Diagnosis: cervical spondylosis Submitted for Pathology: no Surgical Classification: Class 1 Procedure Name: Anterior cervical C6 subtotal corpectomy decompression titanium mesh reconstruction titanium plate internal fixation C3-4 cage placement bone graft fusion Surgeon: (omitted) Assistant: (omitted) Anesthesiologist: (omitted) Assistant Operating Nurse: (omitted) Surgical Steps: General anesthesia induced successfully. Patient in supine position, thin pillow under shoulder and back, neck slightly extended, routine iodine alcohol disinfection and draping. Right anterior cervical transverse incision about 6 cm. Incised skin and subcutaneous tissue, transected platysma, separated between vascular sheath and visceral sheath, exposed to anterior edge of C5 vertebral body, incised prevertebral fascia, fluoroscopy confirmed C6 vertebral body. Subtotal resection of C6 vertebral body and C6/7, C5/6 intervertebral discs with decompression. Preserved lower C5 and upper C7 hard endplates. Intraoperatively visible C6-7 and C5-6 disc protrusions and peripheral vertebral osteophytes, jointly compressing the spinal cord. Cancellous bone fragments from decompression packed into 10 mm diameter 22 mm length titanium mesh, implanted into decompression groove, fixed 37.5 mm Zephir titanium plate to near lower C5 endplate and upper C7 endplate with 4 screws of 13 mm length, performed C3-4 intervertebral decompression, inserted 12 mm wide 5 mm thick cage. Fluoroscopy showed satisfactory position, thorough hemostasis, placed one negative pressure drain, closed incision layer by layer. Surgery completed. Anesthesia satisfactory, bleeding about 100 ml, no transfusion. Anesthesia recovery, patient four limbs movement and sensation same as preoperative. Intraoperative internal fixation provided by Sofamor company Zephir titanium plate titanium mesh system and Stryker company Solis interbody fusion device. Time: 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 at admission: neck and shoulder pain for three years, aggravated with right upper limb pain and numbness for more than one month. Cervical physiological curvature present (as in original), right Hoffmann sign (+-), right biceps reflex diminished, bilateral triceps and brachioradialis reflexes normal, right upper limb pinprick sensation decreased, right lower limb lateral calf and dorsum of foot pinprick sensation decreased. Bilateral knee reflexes normal. Main laboratory results: March 28 blood and urine routine basically normal, hepatitis B surface antigen (-), hepatitis C antibody (-), liver and kidney function, blood glucose indicators basically normal. Special examinations and important consultations (with dates and examination numbers): March 28 electrocardiogram: normal. March 29 cervical MRI: cervical degenerative changes, C3-4, C5-6, C6-7 intervertebral disc degeneration with posterior protrusion. April 3 cervical AP and lateral films: internal fixation position satisfactory. Disease course and treatment results (with procedure name, surgery date, transfusion volume and resuscitation details): After admission examinations showed no obvious surgical contraindications, on March 31 under general anesthesia underwent anterior cervical C3-4 discectomy interbody fusion cage placement C6 subtotal corpectomy titanium mesh reconstruction titanium plate internal fixation. Surgery went smoothly, postoperative routine anti-inflammatory to prevent infection. Review cervical X-ray showed: internal fixation position good, fixation secure. Recovery good, discharged. Complications: none Condition at discharge (symptoms and signs): General condition good, felt pain in posterior neck, no other special discomfort complaints Physical examination: clear consciousness, smooth breathing Neck wound: I/healing by first intention, sutures removed, both upper limbs movement and sensation good, peripheral circulation excellent. Post-discharge medications and recommendations: 1. Actively perform functional exercises, wear cervical collar during activities for three months 2. Outpatient follow-up 3. Indomethacin * 3 boxes, three times daily, one capsule each time, oral Treatment result: cured April 8
Postoperative patient complaints: The original symptoms not only did not improve, but added many discomforts. Head and neck stiffness, completely unable to turn. Originally my head did not hurt, now the head has started to hurt Originally only numbness in a few fingers of the right hand, now both hands completely numb, and the entire shoulder and back feel heavily burdened, all day like carrying dozens of pounds of rice. The chest also always feels tight