Review Question - QID 1312

The clinical picture is consistent with progressive cervical myelopathy, and the best treatment option is an anterior cervical discectomy and fusion. Because there is compression at C4/5 and C5/6, an ACDF would need to be done at both levels.

The patient has signs and symptoms of progressive myelopathy, such as difficulty with tandem gait, buttoning his shirt, and positive Hoffman's reflexes. While the patient does not have all the classic positive signs (i.e. the patient has no clonus and down-going Babinski signs), a diagnosis of myelopathy does not require all signs be present. Furthermore, the imaging studies demonstrate significant cord compression behind the C4/5 and C5/6 intervertebral disc. The best treatment is an ACDF.

Rhee et al. reported on the prevalence of myelopathic signs in patients with known myelopathy. They reported that 79% of patients demonstrated at least one myelopathic sign, with a Hoffman's sign being the most common (59%). Comparatively, an up-going Babinski sign and clonus were each only present in 13% of patients with myelopathy.

Herkowitz et al. reported similar efficacy when treating patients with a cervical disc herniations either from the front with an anterior cervical discectomy and fusion, or from the back with a posterior cervical laminotomy-foraminotomy. However, all patients with myelopathy and midline compression (like the patient in the current question) underwent an ACDF.

Figure A is a sagittal T2 MRI demonstrating cord compression at the C4/5 and C5/6 level, and Figures B and C demonstrates cord compression on the axial series.

Incorrect Answers
Answers 1-3: These are all non-operative treatments. Given that the patient is having progressive cervical myelopathy, there is no further indication for non-operative care.
Answer 5: Posterior cervical laminotomy-foraminotomy would not adequately decompress the spinal cord.