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Case Study: OPLL
J is a very pleasant 55-year-old gentleman who lives in the Texas area. He had undergone a non-instrumented C6-C7 anterior cervical fusion over 20 years ago by a local provider. The new symptoms came on gradually over number of days and involved the left side of his neck, left scapula, and left upper extremity into his fourth and fifth fingers. He ranged his pain at a level of 7 to 8 out of 10. He had undergone physical therapy for this and some of the numbness and tingling has improved slightly. NSAIDs and oral steroids were also administered. However, the weakness of the hand was progressing. During the workup for the C8 radiculopathy, he was found to have severe cervical stenosis and ossification of the posterior longitudinal ligament (OPLL).
He was offered complex cervical spine surgery locally, but was not comfortable with the approach the surgeons were offering. Therefore, he sought us out for a third opinion. We worked with Jeff over the phone for 2 months prior to him traveling to our office. During this time we coordinated with his local primary care provider to optimize his general health, including weight loss and diabetic control.
Given his travel from home to come to our office for treatment, a consult was arranged on a Monday. While we had numerous discussions with Jeff prior to his arrival, we spent a significant amount of time with J and his wife listening to his concerns. We then conducted a thorough physical exam and reviewed his imaging studies (MRI, cervical x rays including flexion and extension views, and carotid ultrasound) in person, showing Jeff the pathology of concern. We then detailed the proposed surgical procedure. Given the degree of compression anteriorly from the OPLL, a staged anterior (stage 1) decompression utilizing multilevel corpectomy, instrumentation and fusion, followed by a posterior (stage 2) decompression, lateral mass screw instrumentation and fusion. Stage 1 was arranged for the day after his consult, and Stage 2 the day after Stage 1.
Stage 1 surgery consisted of an anterior approach for exploration of the old C6-C7 fusion, followed by C4 and C5 corpectomies, radius allograft bone strut fusion, and plating from C3-C6. The surgical decompression was extremely difficult given the degree of OPLL encountered. Pinhole leaks in the CSF were encountered during the decompression as expected, and a lumbar drain was placed during the Stage 1 procedure to reduce the risk of post op CSF leak. Jeff was able to be extubated after surgery, and experienced minimal swallowing complaints.
The following morning, the patient underwent Stage 2, consisting of a posterior C3-T1 decompression, lateral mass screw instrumentation, iliac crest bone graft harvest (due to his brittle diabetes, autograph was utilized) and fusion.
During his hospital stay, pain medications were transitioned from IV to oral route, and activity was increased. He was seen in consultation by physical therapy, occupational therapy, and physiatry (rehabilitation doctor). Activity was gradually increased. His lumbar drain was removed on his 3rd post op day. The posterior drain was removed on his 5th post op day. He was then transferred to the inpatient rehabilitation unit on his 9th post operative day. There he received extensive therapy, allowing him to maximize his conditioning before returning home to Texas.
J was seen back in the office for a 2 week post op visit and was doing exceedingly well. He experienced a significant improvement of his preoperative complaints. He flew home later that day. The patient returned at 3 months post op, and x rays showed complete fusion was achieved. Activity restrictions were gradually lifted, and Jeff resumed normal activities. He came back to see us for a one year follow up and showed great improvement. He even had resumed guitar playing, something he was not able to continue prior to surgery.