History :
A 57-year-old man presented with neck pain, accompanied by radiating pain in both his upper and lower limbs, which had progressively worsened over the past month. He also reported weakness in his right upper and lower limbs for the past 10 days, and difficulty walking for the last 7-8 months. Additionally, the patient experienced imbalance and slipping of footwear for the past 5-6 months. Recently, he noticed a decline in fine motor skills, such as difficulty buttoning clothes, combing hair, or holding small objects, which began 6 days ago.
These symptoms are indicative of cervical myelopathy, where compression or irritation of the spinal cord in the neck region leads to neurological deficits. Best Spine Surgeon in Pune Dr. Sangram Rajale identified that this condition can be caused by factors such as degenerative changes, disc herniation, or spinal stenosis. Prompt treatment for cervical myelopathy is crucial, with surgical decompression often required in severe cases to relieve pressure on the spinal cord and prevent further neurological damage.
O/E CERVICAL SPINE
The patient exhibited several neurological symptoms:
– Festinating gait with loss of balance
– Positive Romberg’s test
– Increased bilateral tone
– Loss of coordination between the right upper and lower limbs
– Right thigh muscle wasting
These findings indicated a serious neurological condition affecting motor control, coordination, and muscle tone.
MRI FINDINGS :
– Myelomalacia changes at C4-5 and C6-7
– Presence of posterior osteophytes at multiple levels
– Prolapsed intervertebral disc
These findings pointed to cervical spine degeneration with compression of the spinal cord and nerves, consistent with the diagnosis of cervical myelopathy. Top Spine Surgeon in Pune Dr. Sangram Rajale confirmed the need for surgical intervention based on these findings.
Operation :
On December 13, 2022, the patient underwent anterior cervical discectomy and fusion surgeries at the C4-C5 and C6-C7 levels. The surgery, performed by Best Spine Specialist in Pune Dr. Sangram Rajale, aimed to decompress the spinal cord and relieve pressure caused by the osteophyte and disc complex. The implants used were from Jesco, and the surgery was carried out under general anesthesia.
Condition On Discharge :
- The patient was stable upon discharge.
- He could walk with full weight-bearing without any external support.
- There was up to 90% relief from upper limb radicular pain.
FOLLOW-UP (SIX MONTHS LATER):
- The patient is now fully functional, demonstrating significant improvement in mobility and daily activities.
- He resumed work two months post-discharge, reflecting a successful recovery.
- Overall, the patient has made excellent progress, showcasing the success of the surgery performed by Best Spine Surgeon in Pune Dr. Sangram Rajale