The patient is a 63-year-old Caucasian man. He is 1.61 meters tall and weighs 66 kilograms. After working as a car mechanic for 36 years, he had been receiving disability benefits for 11 years. He was working part-time as a caretaker averaging 10 hours per week until two and a half years ago. At the age of 35, the patient began having bouts of severe back pain approximately twice a year. When these episodes occurred, he took non-steroidal anti-inflammatory drugs for three to four weeks for pain relief. At the age of 40, lumbar spondylolisthesis was diagnosed by radiography. At the age of 50, he suddenly developed severe right hip pain. He suffered from substantial arthrosis on the right side, which was treated with a total hip replacement one year later.
Three years ago, he began to develop neurological symptoms in both hands. Pain and loss of function of his fingers prevented him from working as a caretaker. The pain radiated from his neck bilaterally down to his fingers and was described as parasthesia-like in nature. He also complained of weakness in his hands. Left hand digit flexion was classified as J1 and right hand as J4. Digit extension was classified as J4 on the left and J2 on the right and abduction on the left was classified as J0 and on the right as J1. The patient also had difficulty walking (Nurick 4, EMS 10/18) as he had to support himself using his surroundings in order to stand upright and was unable to walk unassisted. He was referred to a neurologist by his general practitioner who in turn referred him to a neurosurgeon. Radiographs (Figure 1) magnetic resonance imaging (Figure 2) and computed tomography (CT) revealed a spondylolisthesis between C7 and T1. Using the Meyerding classification [8], which was initially developed for grading the degree of lumbar spondylolisthesis, the patient would have been diagnosed with a cervico-thoracic spondylolisthesis of the second or third degree. The spondylolisthesis, measured using the method developed by Kawasaki et al. [9], was 13 mm. In view of the special nature of the case, a collaborative treatment between neurosurgeons and orthopedic surgeons was favored and subsequently implemented.
The surgical management was performed as follows:
The patient was placed in the supine position. The intervertebral disk at C7-T1 was exposed using blunt dissection. The disk was then removed to the point of the ligamentum flavum. A subsequent resection of the lateral parts of the intervertebral discs significantly mobilized the spondylolisthesis.
The wound was closed and the patient was rotated to the prone position. First, the dislocation between vertebras C7 and T1 was reduced while positioning the head.
Subsequently, the lateral masses were prepared from a dorsal approach between C5 and T3. Then, lateral mass-screws were inserted into C5 and C6. We had noticed considerable laxity between C6 and C7. In addition, C5 and C6 were naturally fused and we decided to include them in the instrumentation. There was also a rigid displacement between C7 and T1.
Bicortical screws were then inserted into the transverse processes of T2 and T3. These were inserted into at least two segments from both sides in divergent directions. The length of these screws was 10 to 12 mm, with a diameter of 3.2 mm.
This was followed by a laminectomy. Since the roots of C7 and C8 were exposed, the lateral masses of C7 and C8 had to be resected. Longitudinal rods were placed. Proper reduction in lordosis and the preservation of a 5 mm intervertebral space between C7 and T1 were confirmed by radiograph. Set screws were used to fix the instrumentation in the desired position. Chips of cortical and cancellous bone were placed lateral to the longitudinal rods.
The dorsal wound was then closed. The patient was again rotated to the supine position to reopen the ventral wound. Now, instead of the previously seen displacement, a large gap was visible between C7 and T1. The endplates between C7 and T1 were milled and the ligamentum flavum was resected using punches. Then, the spinal canal was exposed completely, using a Caspar opener.
Subsequently, a Harms basket, filled with autograft bone chips, was inserted into the intervertebral space. Three drains were placed and the wound was closed. For prophylactic infection control, the patient was perioperatively given intravenous 1.5 g cefuroxime twice a day for the next four days. Intraoperative and postoperative radiographs (Figure 3 and 4) were taken to confirm correct placement of the instrumentation.
Following the operation, the patient was transferred to the intensive care unit. His vital signs were stable enough for him to be transferred to the general postoperative recovery ward on the fourth postoperative day. Eleven days after surgery, the patient left the hospital and entered an orthopedic and neurologic rehabilitation program.
The pain and parasthesias in his fingers resolved after the operation. Two months postoperatively, his ability to walk had noticeably improved after completing his rehabilitation program (Nurick 3).
Today, two years postoperatively, the patient is able to walk without assistance (Nurick 2). Flexion of the fingers on his left hand was graded as J3 and as J5 on the right hand. Extension of the fingers on his left hand was graded as J4 and as J2 on the right. Abduction was graded as J4 for his left hand and as J2 for his right hand (EMS 14/18).
