Had previous fusion of C5-C6 in 2014. Very good results with all symptoms clearing up almost immediately.
Had a fall recently that caused some issues in my neck. Here are some notes.
Presents for follow-up after his recent hospitalization with fall and central cord syndrome. He had fractured his anterior C7-T1 osteophyte and found to have pre-existing central canal narrowing. He states his hands have significantly improved. He has some burning in his hand. He is on lyrica and additional gabapentin
NEUROLOGICAL: Awake, alert, oriented x3. Motor strength 5/5 in all four extremities and all muscle groups. Muscle tone and bulk within normal limits. Reflexes 3+ bilateral upper extremities, 3+ bilateral lower extremities. Toes down going. Sensory examination intact. Cranial nerves II-XII intact. Speech fluent.
MUSCULOSKELETAL: No joint swelling or erythema. No midline cervical, lumbar, or thoracic pain to palpation. Cervical collar limits range of motion in flexion and extension of the cervical spine. The patient ambulates with steady gait.
We reviewed his MRI again which demonstrates diffuse central canal stenosis, most pronounced at C4-5, C5-6, C6-7. There is large anterior flowing osteophyte and ossification of the PLL. Prior ACDF noted.
This 52 Y male is seen in neurosurgical follow-up for central cord syndrome and anterior osteophyte fracture.
We discussed with his central canal stenosis and mylepathic findings, I would recommend consideration of surgical decompression. He isn't ready to commit yet. This would require a minimum of Posterior C3-T2 due to central canal narrowing and the C7-T1 osteophyte fracture. He will consider.
We discussed the risks, benefits and alternatives to operative intervention. The risks include, but are not limited to: bleeding, infection, damage to surrounding structures, need for additional procedures, failure to improve symptoms, spinal fluid leak, weakness, loss of vision or blindness, paralysis, risk of receiving blood products if needed, risks of anesthesia including heart attack, stroke, coma, or death.
Continue cervical collar for 4 additional weeks and then CT C spine without contrast to evaluate healing of the C7-T1 fracture.
Greater than 25 minutes was spent with the patient, of which greater than 50 percent of the time was spent counseling the patient regarding his/her disease condition, imaging findings, and proposed treatment plans, as well as risks, benefits, and alternatives.
Anyone have this many levels done at once. I had no pain or symptoms prior to my fall a few weeks ago that I am aware of. Still having nerve issues in my forearms and hands. Dr. says this is preventative surgery, and may not fix any issues I currently have.