The Journal of Bone and Joint Surgery

Image Quiz

Nontraumatic Cervical Myelopathy¹

A sixty-two-year-old woman with no prior neck problems was referred for evaluation because of a two-week history of neck pain with progressive tetraparesis. She reported the onset of severe neck pain radiating into the shoulders. There had been no antecedent trauma. Two days prior to admission, she had had increasing numbness in both hands with decreased grip strength and increasing leg weakness. She reported no incontinence. She had had a weight loss of 10 to 15 lb (4.5 to 6.8 kg) over several months and had felt generally unwell.

The patient's medical history included long-standing medication-resistant hypertension and mild chronic renal failure with a creatinine level of 200 mol/L. She also had a history of congestive heart failure, and fourteen years before the onset of the severe neck pain, she had had a cerebrovascular accident on the left side, with a minimal residual deficit consisting of a right facial droop. She reported episodes of gout in the past and ongoing problems with constipation and arthralgias.

Physical examination revealed posterior tenderness in the midcervical region. Neurologically, the patient required support for walking because of poor balance and weakness. The upper-extremity strength was 4 of 5 in all muscle groups, according to the classification system of the American Spinal Injury Association². The motor power of the right lower extremity was 3 of 5 in all muscle groups with the exception of the extensor hallucis longus, which was graded 4 of 5. The left lower extremity was normal with the exception of the hip flexors, which were graded 3 of 5. Sensation to light touch and pinprick was normal, but proprioception was abnormal. Reflexes were brisk, with bilateral upgoing toes and a positive Hoffmann sign in the upper extremities.

Radiographs of the cervical spine revealed diffuse osteopenia. There was a 25% anterior spondylolisthesis of the third on the fourth cervical vertebra and a 50% anterior spondylolisthesis of the fourth on the fifth cervical vertebra (Fig. 1). The disc heights at the third and fourth and the fourth and fifth cervical levels were severely reduced. The facet joints at these vertebral levels were not well visualized. Magnetic resonance imaging showed a reduction in the anterior-posterior diameter of the spinal canal to 8 mm at the fourth and fifth cervical levels (Fig. 2). T2 sequencing showed spinal cord compression at the fourth and fifth cervical levels and mild hyperintensity consistent with cord edema. The lateral masses of the fourth cervical vertebra were not well defined.

For larger view, click on image

Fig. 1: Preoperative lateral radiograph of the cervical spine, revealing a 25% anterior spondylolisthesis of the third on the fourth cervical vertebra and a 50% anterior spondylolisthesis of the fourth on the fifth cervical vertebra. The disc heights are severely reduced at these vertebral levels. The facet joints were not well visualized.

Fig. 2: Sagittal T2 sequenced image of the cervical spine, showing a reduction in the anterior-posterior diameter of the spinal canal to 8 mm at the fourth and fifth cervical levels.

The patient was admitted to the hospital, where she was managed with steroids and placed in tong traction. Within forty-eight hours, the spondylolisthesis of the third on the fourth cervical vertebra was reduced anatomically and that of the fourth on the fifth cervical vertebra was corrected to 20%. There was a gradual decrease in the neurologic symptoms. The working diagnosis was cervical instability secondary to an osseous destructive process resulting in myelopathy.

What is the differential diagnosis?