SpineUniverse Case Study Library

Cervical Myelopathy: Difficulty with Rapid Fine Hand Movements


A 64-year-old man had a C4-C6 laminectomy performed 3 years ago for myelopathy due to stenosis. His myelopathy improved, and he did well for a year.

He then began to develop increasing neck pain, and his myelopathic symptoms began to return. Additionally he began to have great difficulty holding his head up.


Clinically, his neck alignment appeared to be normal when he was supine.

On examination, his head was markedly flexed in neutral. He had difficulty with rapid fine movements of his hands. His gait was slow and stiff. He had bilateral Hoffman’s signs and positive Babinski’s signs.

Pre-Treatment Images

fig1 Traynelis 64yo Cervical Myelopathy Pre-op Lat X-rayFigure 1: Neutral lateral radiograph. Image courtesy of Vincent Traynelis, MD, and SpineUniverse.com.

fig2 Traynelis 64yo Cervical Myelopathy Pre-op Midsag CTFigure 2: Midsagittal CT scan demonstrates marked improvement in alignment. Image courtesy of Vincent Traynelis, MD, and SpineUniverse.com.

fig3 Traynelis 64yo Cervical Myelopathy Pre-op Sag T2-weighted MRIFigure 3: Sagittal T2-weighted MRI shows loss of lordosis and a disc herniation and obvious stenosis at C6-C7. Image courtesy of Vincent Traynelis, MD, and SpineUniverse.com.

fig4 Traynelis 64yo Cervical Myelopathy Pre-op Axial C4 MRIFigure 4: Axial MRI at C4 demonstrates consistent cord compression. Image courtesy of Vincent Traynelis, MD, and SpineUniverse.com.


The patient was diagnosed with cervical myelopathy.

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Selected Treatment

The patient was treated with anterior C3-C4, C4-C5, C5-C6, C6-C7, and C7-T1 decompressions and fusions.  The patient also had a C3 to T1 posterolateral instrumented fusion, all under a single anesthesia. 

Post-treatment Images

fig5 Traynelis 64yo Cervical Myelopathy Post-op Lat X-rayFigure 5: An early post-operative lateral radiograph showing instrumentation. Image courtesy of Vincent Traynelis, MD, and SpineUniverse.com.

fig6 Traynelis 64yo Cervical Myelopathy Post-op CTFigure 6: CT scan at 1-year post-surgery shows restoration of lordosis and solid arthrodeses at each level. Image courtesy of Vincent Traynelis, MD, and SpineUniverse.com.


The patient’s lordosis was restored, and his myelopathic symptoms resolved. At 1-year post-surgery, he had minimal neck pain.

Case Discussion

This is an interesting patient with a superb technical result facing a common but challenging problem for any surgeon dealing in cervical spine disorders.

Postlaminectomy kyphosis has been reported to occur in up to 20% of patients who have loss or lordosis preoperatively. The cause of the myelopathy is probably vascular with draping of the cord over the anterior osteophytes.

The challenge is in the reconstruction. In this example, an extensive anterior/posterior reconstruction is performed with a 5-level anterior fusion and decompression.

We know that multilevel anterior level decompressions and interbody fusions work better than corpectomies in restoring lordosis.

How many levels are enough? With a prior posterior approach and multiple levels, adding a posterior tension band is very reasonable and extending it into the thoracic spine appropriate.

I think the surgeon should be congratulated on demonstrating amazing technical ability to perform a 5-level approach from the front.

This is my only point of contention. He appears to have a somewhat flexible kyphosis. On the CT, he is not kyphotic. C3-C4 has also not been decompressed.

At 64, having a high and simultaneous neck dissection puts him at risk of profound and persistent dysphagia. Not all instrumentation sets are made for 5 levels as well and it may force the surgeon to use an unfamiliar system.

In my hands, I probably would have limited the anterior reconstruction to 3 levels, C4-C7 and then decompressed C3-C4, C6-C7 and C7-T1 posteriorly in addition to the C3-T1 instrumentation. I think this would have achieved the goals of correction of sagittal balance, decompression and stabilization with hopeful improvement of myelopathic symptoms without adding the morbidity associated with a 5 level anterior dissection. Nevertheless, this is another option to what is a surgical very well managed case. 

Community Case Discussion (3 comments)

SpineUniverse invites spine professionals to share their thoughts on this case.

A longitudinal "carotid" exposure helps to reduce surgical morbidity including dysphagia. Also, it provides a more extensile exposure. I would have extended the posterior instrumentation to T2 or even T4 to prevent failure of the lower fixation points. I agree that C3-4 could possibly have been addressed posterior only with less mobilization of the pharynx needed. Excellent case. It highlights the dangers of posterior cervical laminectomy without fusion.

I guess I dont understand why front back? Posterior fusions have an excellent fusion rate, and the deformity is minimal. Seems like risking a lot a dysphagia for limited gain. If a level doesn't want to fuse then go back and do an acdf a year later. And why stop at c3? Just setting yourself up for adjacent level issue. C2 to t2 and be done with it.

I might be concerned about excessive movement of the C1-2 articulation. Being responsible for 40% rotation, with this fusion the patient might try and overcompensate for limited ROM (looking into rear view window).

With constant C1-2 excessive compensatory rotational movements I fear the C1-2 joint will develop an excessive lateral osteophytic flange which could give rise to traumatizing the vertebral artery. In addition, the long term outcome may give rise to C1-2 disease and become unstable.

Has anyone heard of this, and how could it be treated?


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