Clinical case

Advanced cervical spine surgery

Case of extreme difficulty in which we find a 59-year-old patient who suffers from great chronic cervical pain as well as paresthesias in MMSS, tingling in the upper limbs, bilaterally.

It is appreciated a progressive deterioration of general condition due to pain caused by muscle contractures that make it difficult for the patient to carry out their daily lives.

Preoperative

In the last year, the patient has suffered a progressive functional deterioration and a gradual increase in pain that conditions him and makes it difficult for him to fall asleep, as well as carry out his daily activities.

After performing the correct clinical examination, as well as analyzing the MRI and X-ray study, a severe canal stenosis at the level of the 4th and 5th of the cervical vertebrae. Foraminal stenosis is also observed bilaterally between the 6th and 7th vertebrae, in addition to a cervical disc herniation at C4C5.

At the level of C5C6 the patient presents a natural fusion that has probably been the cause of the progressive deterioration in the adjacent levels and the intense pain he suffers.

After the failure of medical treatment and RHB, the patient is informed of the need for surgery since it is considered the best option for the advanced spinal damage suffered.

Operation

In view of the operation, the objective is:

C4-C5 myelopathy with severe disc disease and posterior osteophytosis.
Klipel Feil C5-C6 Fusion
Severe C6-C7 discopathy with foraminal stenosis and posterior osteophytosis and lateral osteophyte bars

After which:

C4-C5 anterior discectomy and interbody arthrodesis with PEEK titanium and autologous graft and ABC plate, adding dural coverage with Lyoplant
Anterior discectomy C6-C7. Bilateral foraminotomy/osteophytic bars and C6-C7 Activ C arthroplasty
Satisfactory radiological control is observed.

Postoperative

The patient wakes up feeling virtually no pain and with complete cervical mobility two hours after the operation.
After 4 hours he is able to sit up and eat his first foods.
He is encouraged to take short walks without a corset and has no pain or limitations when doing them. Only with 4 hours of recovery
After 24 hours since surgery, the patient leaves the hospital with a medical discharge. Having been prescribed mild medication orally and with practically no discomfort.