Progressive Myelopathy from a Cervical Disc Herniation
A 48-year-old man presents with 3 months of progressive clumsiness of both hands, difficulty with fine motor tasks, and unsteady gait. He reports neck pain radiating to the right arm with numbness in the thumb and index finger. Examination shows hyperreflexia in the legs, a positive Hoffmann sign, and mild spasticity, with reduced pinprick sensation in the C6 distribution on the right. MRI shows a large right paracentral disc herniation at C5–C6 compressing the spinal cord, with T2 hyperintensity within the cord at that level. There is no fracture or instability. He works as a carpenter and drives.
1. What is your diagnosis and urgency of intervention, and what does the cord signal change mean?
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The presentation is a cervical spondylotic myelopathy caused by a right paracentral C5–C6 disc herniation, with a C6 radiculopathy component. The upper motor neuron signs (hyperreflexia, Hoffmann, spasticity) and gait disturbance indicate cord compression.
Urgency: this is a progressive myelopathy, which is a surgical emergency of a semi-elective nature - deterioration can be stepwise and irreversible. The presence of T2 hyperintensity within the cord indicates edema/gliosis from compression and is associated with a worse prognosis and a higher risk of irreversible deficit. Surgery should not be delayed once significant or progressive myelopathy is documented.
The key judgement is that the radicular symptoms are less important than the myelopathic signs; the decision is driven by the cord compression and the trajectory, not by the arm pain alone.
2. How do you choose between anterior cervical discectomy and fusion, disc arthroplasty, and posterior decompression?
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Decision factors include the location and number of levels, the presence of instability, the patient's age and activity level, and the surgeon's experience.
- Anterior cervical discectomy and fusion (ACDF) - appropriate for a single-level anterior or paracentral disc herniation with myelopathy. It directly addresses the compressive lesion and restores/maintains lordosis. Fusion is reliable but sacrifices motion.
- Cervical disc arthroplasty - an option for single-level disease in selected younger, active patients without significant facet arthropathy or instability. It preserves motion but has specific contraindications and requires careful patient selection.
- Posterior decompression (laminectomy or laminoplasty) - better for multilevel disease, congenital stenosis, or posterior compressive pathology. It risks worsening alignment and requires adequate lordosis; laminoplasty preserves motion and reduces the risk of postlaminectomy kyphosis.
For this patient with a single-level large disc herniation and cord signal change, an anterior approach (ACDF or arthroplasty) is generally preferred. Counsel him about the risks of recurrent laryngeal nerve injury, dysphagia, adjacent segment disease, and the possibility of incomplete neurological recovery.
3. What are the perioperative and rehabilitation considerations given his occupation and the cord signal change?
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- Perioperative - optimize general health, discuss anesthetic risk, and plan for neuromonitoring (e.g., MEP/SSEP) during surgery. Avoid hypotension and hypoxia; maintain spinal cord perfusion. Consider steroids only if there is significant edema, with attention to glucose control.
- Cord signal change - counsel that recovery may be incomplete and that residual spasticity or sensory deficits are possible. Document baseline neurological status for comparison.
- Rehabilitation - early mobilization, occupational therapy for fine motor tasks, and gait training. Anticipate a period away from carpentry work; discuss lifting restrictions and return-to-work timelines.
- Driving - advise against driving until gait and reaction times are safe; document the discussion.
- Follow-up - serial clinical and imaging follow-up to monitor for adjacent segment disease and recurrence.
The judgement is to balance the urgency of decompression against the realities of his occupation and the prognostic implications of the cord signal change.