History :
65 year old gentleman farmer by occupation came with complains of Neck pain since 4 years and loss of balance associated with frequent fall while walking since 3-4 months. His most recent fall was 10 days back. He was unable to hold tea cup, spoon water glass etc, due to weakness in his hand. His ability to do small jobs (fine motor skills ) like buttoning unbuttoning shirt , combing hair, using cell phone etc, was difficult for him. He was also suffering from constipation and urgency to pass urine was present. present. History of bilateral upper limb tingling since 4 months. He also was a chronic alcoholic due to which he had Alcohol-related cerebellar degeneration.
O/E of neck –
His neck movements were limited in all directions While walking he often lost balance and use to fall.
MRI :
The MRI findings show degenerative changes in the neck spine, including bulging discs and bone growths (osteophytes). These changes are causing pressure on the protective sac around the spinal cord and narrowing of spaces where nerves exit the spine. As a result, the nerves leaving the spine are being compressed, which can lead to symptoms such as neck pain, arm pain, weakness, or numbness.
Degenerative Changes in Cervical Spine:
This indicates age-related wear and tear affecting the vertebrae and discs in the neck region.
Mild Disc Bulge with Posterior Marginal Osteophyte Formation:
C3-C4, C4-C5, C6-C7 Levels: Refers to specific segments of the cervical spine. Ventral Thecal Sac Indentation: The thecal sac is a protective covering around the spinal cord. Indentation means that something is pressing against it. Bilateral Lateral Recess and Neural Foramina Compromise: The lateral recess and neural foramina are spaces where nerves exit the spine. Compromise means these spaces are narrowed or compressed. Compressing Bilateral Exiting Nerve Roots: The nerves that exit the spine on both sides are being compressed or squeezed.
Hard Disc Bulge at C5-C6 Level:
Ventral Thecal Sac Indentation: Similar to above, indicating pressure on the protective sac around the spinal cord. Bilateral Lateral Recess and Neural Foramina Compromise: Narrowing or compression of spaces where nerves exit the spine.
Compressing Bilateral Exiting Nerve Roots:
Compression of nerves as they leave the spine.
Operation :
The patient underwent an operation known as C5-C6 Anterior Cervical Discectomy and Fusion on 13/04/2023 under general anesthesia. The procedure was performed by Dr. Sangram Rajale, and
Jayon implants were used. Specifically, Proless Hybrid Cage Lordotic implants, one with a size of 7mm and another with a size of 6mm, were utilized during the surgery.
Condition On Discharge :
After undergoing the ACDF surgery for his cervical myelopathy, he was stabilized post-surgery and taken to his room, although he didn’t notice significant improvement immediately. However, over time, he experienced a noticeable improvement in his hand disability, indicating that the surgery successfully addressed the nerve compression in his cervical spine. About two months after the surgery, he began to see improvements in his balance, and eventually, he was able to return to work. Overall, his recovery has been very satisfactory, and he is grateful for the positive impact the surgery has had on his quality of life and functionality.