Case 14: cervical epidural mass

posted: January 26, 1997

Resident: L.Jacques, MD
Attendings: Deepak Awasthi, MD (Neurosurgery) and Mitch Harris, MD (Orthopedics)

CLINICAL PRESENTATION: This 41 wm presented to the neurosurgery clinic with the chief complaint of neck and bilateral shoulder pain. He also complained of an "electrical shock-like" feeling down the back of his spine when in extension. In addition, he states that his hands go "numb" and ,at times, hypersthetic with certain neck movements (especially extension). He denies any motor weakness, difficulty walking, bowel/bladder difficulties. The patient is a preacher and has been suffering with the current neck pain for about 6-9 months. He denies any history of trauma. About 3 years prior to this visit, the patient had a C5-6 anterior cervical discectomy and fusion for a "disc herniation". At that time, his complains included neck pain and right arm pain with tingling in the hand. The symptoms improved postoperatively, only to recur as stated above about 6-9 months ago. The hand symptoms described above are more recent (about 3 weeks prior to the clinic visit). Patient's medical history is significant for insulin-dependent diabetes mellitus.

EXAMINATION: Decrease range of motion in the neck with posterior paraspinous muscle spasms and tenderness. Very short neck in this obese man. Normal motor strength throughout. Sensory exam intact to pinprick, light touch, and propioception. Diminshed vibratory sensation in both feet. No spasticity. Reflexes normal throughout. No pathological reflexes. Gait normal. No Romberg sign.

Remainder of the neurological and general examination normal.

DIAGNOSTIC STUDIES: The initial study this patient had was a MRI scan of the cervical spine. A representative sagittal T1-weighted image is shown below:

Red marker is pointing to a ventral epidural mass with cord compression (C2-C5). Also note the C5-6 anterior fusion (white marker). The ventral mass is hypointense (as a matter of fact it was hypointense in all sequences).

What is the differential diagnosis?

Please comment: dawast@lsuhsc.edu

The above study was followed by a myelogram and a post-myelogram CT scan of the cervical spine. A representative axial view of the post-myelo CT scan is shown below at the low C2 level.

Note the lack of dye at this level and the ossification of the posterior longitudinal ligament. Thus, this patient's diagnosis is OPLL.

How would you proceed at this point? Surgery v. no-surgery? If surgery, anterior v. posterior?

Please comment: dawast@lsuhsc.edu

STEPS TAKEN AT LSU: After presentaion of this case at spine conference, the consensus was to offer this man surgical decompression posteriorly (C2-5) with lateral mass plating and fusion (pedicle fixation of C2).

Thus, a C2-5 decompressive laminectomy was performed after lateral mass fixation from C2 to C6 (pedicle fixation of C2). This was followed by a lateral mass fusion using autograft (iliac crest).

POSTOPERATIVE COURSE: Immediately postop. the patient had profound right hemiparesis, which improved to nearly normal (5/5 in right lower extremity; 3/5 right deltoid, biceps, triceps, wrist extension; 2/5 intrinsic muscle strength in right hand) over the course of 3-4 days. However, the right hand weakness (1-2/5 intrinsic muscle strength) and hyperesthesia perisisted on discharge to rehab. (postop. day 7). Of note, SSEP's were felt to be unchanged throughout the course of the operation.

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