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Case Study 1
Gait and Balance Difficulties in a 76-Year-old Male
Richard G. Fessler, MD, PhD
Professor of Neurological Surgery
Northwestern University
Chicago, IL
History
Because of gait and balance difficulties, the patient, a 76-year-old male, uses a wheelchair.
Examination
Patient's gait is unsteady and broad-based. He can't tandem walk. Muscle testing showed 3/5 left and 0/5 right extensor hallucis longus, and 0/5 right Achilles tendon. Knee reflexes at 3+; all others are zero. His Babinski response and Hoffman's sign were negative.
He has a history of a left craniectomy for meningioma.
Images
MRI shows severe stenosis at C3-C4, C4-C5 and C5-C6 secondary to degenerative subluxation of C4 with spondylosis. There is a kyphotic deformity at C4.
Diagnosis
Degenerative spondylosis with stenosis C4-C6.
Treatment
A C4-C6 corpectomy with fibular strut allograft was performed. Anterior fixation was then performed from C3 to C7 using a translational plate.
Outcome
The patient's strength improved to near normal, but minimal improvement in balance. The patient continued to have difficulty with ambulation.
Case Discussion
Vincent Traynelis, MD
Professor of Neurosurgery
University of Iowa
Iowa City, IA
This elderly gentleman has a gait disturbance that is probably related to spinal cord compression at the cervical level. His hands seemed to be spared and therefore it would be important to evaluate both the thoracic and lumbar regions with MR. This would rule out thoracic spinal cord pathology, or multiple lumbar nerve root compressions, both of which could account for his symptoms.
Although exceedingly rare, a metastatic meningioma could also be detected with MR imaging. Flexion/extension lateral cervical radiographs should also be obtained. If these studies do not add any significant new information, I would favor performing multilevel discectomies at C3-C4, C4-C5, and C5-C6.
There appears to be cerebral spinal fluid behind the vertebral bodies and review of the postoperative lateral radiographs indicates the facets are not fused. A 3-level discectomy approach would adequately decompress the spinal cord, enable proper sagittal realignment, and provide the opportunity to secure the spine with a pair of bicortical screws in each of the affected vertebrae.
After surgery, if the patient did not completely improve within an appropriate timeframe, then another MR scan should be done. If the MR scan shows any remaining, significant spinal cord compromise, then that should be addressed by using a posterior decompression.
Courtesy of Spine Universe
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