Sixty-two-Year-Old Woman with Neck Pain

A sixty-two-year-old woman with no prior neck problems was referred to our institution 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 Association. 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. 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. The differential diagnosis included tumor (probably a metastasis), infection, an inflammatory process, and degenerative and metabolic bone disease. Diagnostic investigations were initiated. Relatively urgent operative intervention was indicated for complete reduction and decompression, stabilization, and tissue biopsy. The patient was then taken to the operating room for an indirect decompression through reduction and for combined anterior and posterior stabilization (Fig. 3). The first stage of this combined procedure included anterior discectomies at the third and fourth and the fourth and fifth cervical levels, reduction, autogenous bone-grafting, and plate application. Grossly, the bone graft appeared to be of poor quality. The second stage, performed during the same operation and through a posterior approach, revealed that most of the right fourth cervical lateral mass was eroded. Tissue was obtained for biopsy. Less extensive erosive changes were noted on the left lateral mass. There was disruption of the intraspinous and supraspinous ligaments at the fourth and fifth cervical levels. Lateral-mass plates and screws and autogenous bone graft were applied from the third to the fifth cervical level. On the basis of the preoperative images and the neurologic improvement that was obtained with closed reduction, it was thought that the patient did not require direct decompression. Postoperatively, the patient wore a cervical orthosis and was able to walk short distances. The neurologic deficits decreased, but she continued to feel unwell and lethargic. The biopsy demonstrated nonspecific reactive changes within cancellous bone. There was no histologic evidence of infection or neoplasm. Additional bone from the iliac-crest bone-graft donor site was also submitted for histologic examination, which demonstrated excessive numbers of osteoclasts, numerous resorption sites, and prominent paratrabecular osteoblastic activity with adjacent fibrosis (Fig. 4). A chest radiograph showed multiple rib fractures and erosions of the lateral ends of the clavicles and the medial aspect of the proximal part of the humeral shaft. A whole-body technetium-99m bone scan demonstrated increased uptake throughout the entire skeleton, suggestive of metabolic bone disease. Radiographs of the hands revealed generalized osteopenia with coarsening of the trabecular pattern and subperiosteal resorption. Osteolysis was present in the distal phalanges, and there were a number of small erosions involving the wrist and the metacarpophalangeal and interphalangeal joints in an asymmetric pattern. A clavicular radiograph revealed distal resorption of both clavicles with widening of the acromioclavicular joints (Fig. 5). A pelvic radiograph showed osteosclerosis of the bones of the lumbar spine and pelvis with widening of the symphysis pubis and resultant formation of a pseudarthrosis. Laboratory tests showed that the level of ionized serum calcium was 1.42 mmol/L (normal range, 1.12 to 1.30 mmol/L) and the level of phosphate was 0.50 mmol/L (normal range, 0.80 to 1.45 mmol/L).