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Physical therapy and NSAIDS
1%
41/3270
High dose methylprednisone
20/3270
C5/6 hardware removal and C4/5 ACDF using a left sided anterior approach
84%
2761/3270
C5/6 hardware removal and C4/5 ACDF using a right sided anterior approach
4%
138/3270
C5 to C7 posterior laminectomy and fusion
9%
287/3270
Select Answer to see Preferred Response
The clinical scenario describes a patient with cervical myelopathy due to an anterior midline disc herniation at the adjacent C4/5 level. In addition, she has voice changes and abnormal vocal cord function likely due to an injury to the left recurrent laryngeal nerve (RLN) during her prior left sided approach. The most appropriate treatment at this time is hardware removal at C5/6 (she is fused) and anterior cervical discectomy and fusion at C4/5 utilizing a left sided approach through her old incision. One should avoid using a right-sided approach, as a right recurrent larygngeal nerve (RLN) injury would cause denervation of both vocal cords leading to breathing difficulties and aphonia. Netterville et al showed that multiple branches of the vagus nerve are are risk during surgery. They also concluded that right-sided approaches carry a greater risk to the recurrent laryngeal nerve as its course is more variable. Kilburg et al reviewed 418 cases and showed no significant difference in RLN injury based on laterality of approach. Steurer et al found that hoarseness following neck surgery may be present with or without the presence of a RLN palsy. They also found patients may have a normal voice despite an RLN palsy. Therefore, they recommend evaluation with laryngoscopy or videostroboscopy in "at risk" patients to identify a RLN palsy. Incorrect Answers: Answer 1 & 2: Because the patient is myelopathic, physical therapy and high dose steroid are not appropriate. Answer 4: See description above. Answer 5: The patient has anterior compression from a midline disc herniation, and therefore a posterior decompression would not adequately address her focal anterior compression.
4.7
(35)
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