SpineUniverse Case Study Library

Cervical Myelopathy with Severe Lumbar Degenerative Disease


A 62-year-old white female presented with the chief complaint of low back pain radiating into the right leg exacerbated by prolonged sitting and valsalva. Her pain was present for approximately 1 year, with acute worsening in the last month. On further questioning, she endorsed numbness and paresthesias of the bilateral hands, as well as unsteadiness of gait.


  • Motor strength was 5/5 throughout, with the exception of 4+/5 power in the right biceps brachii.
  • Sensation was intact, but patient did report paresthesias of the bilateral hands. 
  • Deep tendon reflexes were 3+ in the bilateral upper extremities and Hoffman’s sign was present bilaterally.
  • Reflexes in the lower extremities were normal and without evidence of sustained clonus.

Prior Treatment

The patient's low back pain and radiculopathy was treated  with a 3-month course of physical therapy, as well as non-steroidal anti-inflammatory drugs, with minimal relief. She received this treatment prior to referral to our clinic.

Pre-treatment Imaging

The patient’s chief complaint involved low back pain and radiculopathy, and—as such—a non-contrast MRI of the lumbar spine was acquired that revealed multi-level degenerative disease with spinal canal and neural foraminal stenosis that is worse at L1-L2 and L2-L3, as seen on sagittal images (Fig. 1) and axial images (Fig. 2).

Figure 1. Image courtesy of Jonathan A Tuttle, MD, and SpineUniverse.com.

Figure 2. Image courtesy of Jonathan A Tuttle, MD, and SpineUniverse.com.

Because the patient’s history and physical contained features concerning for cervical myelopathy, non-contrast MRI and CT scans of the cervical spine were acquired.  A large retro-odontoid pannus was noted on sagittal T2-weighted images of the cervical spine causing deformity of the spinal cord at the occipital cervical junction (Fig. 3).  The lesion was eccentric to the right side and displaced the vertebral artery posteriorly (Fig. 4).  Sagittal and axial CT images revealed destruction of the C1 lateral mass bilaterally and of the occipital condyle on the right (Figs. 5 and 6).

Figure 4. Image courtesy of Jonathan A Tuttle, MD, and SpineUniverse.com.

Figure 5. Image courtesy of Jonathan A Tuttle, MD, and SpineUniverse.com.

Figure 6. Image courtesy of Jonathan A Tuttle, MD, and SpineUniverse.com.


The patient was diagnosed with cervical myelopathy secondary to chronic instability at the atlanto-axial and atlanto-occipital joints, as well as lumbar radiculopathy secondary to advanced degenerative disease of the lumbar spine.

Given the association between retro-odontoid pannus formation and rheumatoid arthritis, a rheumatology consultation was obtained, and multiple laboratory tests were sent, including cyclic citrullinated peptide antibody, serum protein electrophoresis, erythrocyte sedimentation rate, C-reactive protein, antinuclear antibody screen, and rheumatoid factor.  The patient had no other signs or symptoms of rheumatologic disease on questioning or examination.

Suggest Treatment

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Selected Treatment

Posterior occipito-cervical fusion without decompression. The patient was treated with in-situ fusion with a posterior plate/screw/rod construct extending from the occiput to C4.

Intra-operative Imaging

Intra-operative fluoroscopic images in the lateral (Fig. 7) and anteroposterior (Fig. 8) projections show the instrumentation in good position, and the patient in good alignment.

Figure 7. Image courtesy of Jonathan A Tuttle, MD, and SpineUniverse.com.

Figure 8. Image courtesy of Jonathan A Tuttle, MD, and SpineUniverse.com.

Post-operative Imaging

Figure 9 shows the pre-operative sagittal T2-weighted MRI (Panel A, left) in comparison to a sagittal T2-weighted MRI, acquired 6-months post-operatively (Panel B, right).

Pre-operative images are on the left and post-operative images are on the right.

Figure 9. Image courtesy of Jonathan A Tuttle, MD, and SpineUniverse.com.

A significant reduction in the size of the retro-odontoid pannus is noted on follow-up imaging with resolution of mass effect and deformity of the spinal cord at the craniocervical junction.  These findings are also apparent on axial sections, as seen in Figure 10.

Pre-operative images are on the left and post-operative images are on the right.

Figure 10. Image courtesy of Jonathan A Tuttle, MD, and SpineUniverse.com.


Our patient experienced complete resolution of her upper extremity symptoms and improvement in her biceps strength.  Her lumbar pathology was ultimately treated through a posterior approach with decompression and fusion spanning from T12 to L3.

Case Discussion

This case illustrates the importance of a comprehensive neurological examination in all spine patients. The patient presented with lower back pain as a main complaint, but the examination revealed increased reflexes and gait issues. The subsequent cervical MRI shows cervical stenosis and C1-C2 pannus formation. My experience is that at least a couple of times a year, patients presenting with lower back pain are found to be myelopathic due to cervical stenosis. Patients may have no neck pain issues, but a positive Hoffman's reflex or clonus suggests obtaining a cervical MRI scan.

The authors elected to do an occiptal to cervical fusion surgery. In most cases, it's best to avoid extending a fusion up to the occiput because of the significant morbidity in terms of decreased head movement. Generally, I would elect to do C1 lateral mass screws. In this case, the C1 lateral masses appear destroyed on the preoperative CT scan and extension to the occiput was necessary. Another option would have been to incorporate a cervical laminectomy, especially at C1 to immediately address cervical stenosis, but the post-operative MRI images show that with a fusion, the pannus regressed and the cervical spinal cord stenosis was alleviated.

Authors' Response

We appreciate Dr. Deutsch's thoughtful comments regarding our case presentation. This case does, indeed, highlight the importance of a thorough history and physical examination for all spine patients in order to avoid misdiagnosis and to ensure proper treatment.

In this case, because of erosion of the C1 lateral masses, we felt fusion to the occiput was necessary to ensure inclusion of all the pathology.

Treatment of the patient's instability resulted in resolution of the retro-odontoid pannus and subsequent decompression of the neural elements. In this case, immediate canal decompression was not necessary as the patient's symptoms were progressing slowly. If this same patient had presented with a rapidly deteriorating neurologic examination, emergent direct surgical decompression would have been mandatory.

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