Simultaneous Cervical and Lumbar Surgery for …

1 Case ReportSimultaneous Cervical and Lumbar Surgery for CombinedSymptomatic Cervical and Lumbar Spinal StenosesSait Naderi and Tansu MertolDepartment of Neurosurgery, School of Medicine, Dokuz Eyl l University,Izmir, TurkeySummary:Spinal stenosis may rarely involve both Cervical and Lumbar spines. Analternative surgical strategy used for the treatment of combined Cervical and lumbarspinal stenosis is presented. Two cases with symptomatic combined stenosis of thecervical and Lumbar spinal canal are described. Simultaneous Surgery wasperformed inboth cases. The combined stenosis of the Cervical and Lumbar spinal canal dictates carefulneurologic and neuroradiologic examinations. Simultaneous Surgery is an alternativeapproach for patients with symptomatic multilevel spinal stenoses, whose general con-ditions necessitate a one-session and short-lasting Words:Combined ste-nosis Lumbar spine Cervical spine Simultaneous the age of the population increases, the rate of de-generative and spondylotic processes of the spine in-creases.

2 Spondylotic processes of the spine may affect thespine either segmentally or more diffusely (1). Althoughthere are many reports on spinal stenosis limited to onesegment of the spine, there are only a few reports oncombined spinal stenoses. According to Epstein, 5% ofpatients with spinal stenosis have symptoms at both levels(2). The combination of spinal stenosis in two levels mayconfuse the clinical picture. At the beginning of the dis-ease, symptoms and signs referable to one level will domi-nate the clinical picture and obscure the second , in the late stage, findings referable to the secondlevel may occur. Such a situation complicates the surgicaldecision-making process and dictates the consideration ofseveral questions, including the priority of the level to bedecompressed, the selection of surgical approach, and theinterval between the interventions for the two levels, ifany.

3 This study reports two patients with such a conditionwho underwent Simultaneous Cervical and Lumbar decom-pressions and discusses several aspects of combined cer-vical and Lumbar spinal REPORTSCase 1A 73-year-old woman was admitted to our hospital be-cause of weakness of both arms and legs for 3 years. Shealso complained of low back pain and pain in both legsafter short periods of walking. The patient had a history ofa C4 5 Cloward operation 6 years before her new admis-sion. A neurologic examination revealed quadriparesis(muscle power: 4/5). There was a hyperactivity of deeptendon reflexes in the four extremities, and Babinski andHoffman reflexes were positive on the left side. She alsohad atherosclerotic heart disease. Cervical radiographsshowed an acquired fusion of C4 5 level and spondyloticchanges of the Cervical spine.

4 Magnetic resonance imag-ing (MRI) of the Cervical spine showed degenerativechanges secondary to previous anterior fusion and loss ofC6 vertebral height as well as posterior stenosis of thecervical spinal canal at the C3 4 level (Fig. 1). A lumbarradiograph and a Lumbar MRI showed L4 5 grade I spon-Received September 4, 2001; accepted November 7, correspondence and reprint requests to Dr. Sait Naderi,Department of Neurosurgery, Dokuz Eyl l University Hospital, Inciralti,35340, Izmir, Turkey. E-mail: of Spinal Disorders & TechniquesVol. 15, No. 3, pp. 229 232 2002 Lippincott Williams & Wilkins, Inc., Philadelphia229dylolisthesis (Fig. 2A and B). Flexion/extension radio-graphs showed a mobile segment at the same level. Thepatient underwent Surgery for a Simultaneous C3 totallaminectomy, L3 laminectomy, and L3 5 transpedicularfixation (Fig.)

5 2C). The Surgery lasted 130 minutes. Thepatient was discharged 7 days after the Surgery and anuneventful postoperative period. She was 2 This 65-year-old woman who lived alone in seniorhousing was admitted to our hospital because of low backpain, right leg pain, weakness of the right arm and rightleg, as well as gait imbalance. The aforementioned com-plaints began 20 years before, after a traffic accident. Hercomplaints increased 2 years ago and her symptoms didnot respond to medical or physical therapies. The patienthad also complained of urinary incontinence for 1 examination revealed a right hemiparesis(muscle power: 4/5). Deep tendon reflexes were hyperac-tive on the right side, and Babinski reflexes were positivebilaterally. There was no sensory deficit.

6 Cervical spineradiographs revealed loss of lordosis and the presence ofspondylotic changes. Cervical MRI showed a central ste-nosis at the level of C4 5 and a dorsolateral C5 6 stenosis(Figs. 3A and 4A and B). Static and dynamic lumbarradiographs showed an unstable L3 4 spine MRI showed spinal stenosis at the level ofL3 4 and L4 5 and a disc herniation at the level of leftL4 5 and right far lateral L4 5 (Fig. 5). The patient un-derwent Simultaneous Lumbar and Cervical decompressionand instrumentation (right L4-5 far lateral discectomy,right L3 hemilaminectomy and right L4 foraminotomy,left L4-5 discectomy, L3-4-5 transpedicular fixation, C4-5posterior discectomy, and C4-5 laminoplasty) (Figs. 3 Band 4C and D). The Surgery lasted 155 minutes. The pa-tient s gait improved in the early postoperative stenosis leads to narrowing of the sagittal diam-eters of the spinal canal and neuroforamina.

7 It occurs mostcommonly in the Cervical and Lumbar area. Depending onthe location of the stenosis, the narrowing of the spinalcanal may cause spinal cord and/or nerve root compres-sion. Besides the segmental stenosis of the spinal canal atthe Cervical or Lumbar spine, the stenosis may rarely in-volve both Cervical and Lumbar spine (3 7). The associa-tion of Cervical and Lumbar spinal stenosis was first re-ported by Teng and Papatheodorou in 1964 (8). Theyreported 12 cases, only 3 of which had both Cervical andlumbar symptoms. Eight patients had pure Cervical spon-dylotic myelopathy, and one patient had signs and symp-FIG. 1. Preoperative imagesof the Cervical :Lateral radio-graph shows a fusion of the C4 5 leveland spondylotic changes of the :Sagittal magnetic resonanceimage of the Cervical spine shows aC4 5 stenosis of the Cervical spinal : Cervical axial magnetic reso-nance image shows posterior stenosisof the spinal : Lumbar radiographshows spondylolisthesis at the level ofL4 : Lumbar magnetic resonanceimage shows L4-5 degenerative :Postoperative Lumbar radio-graphs show L3 5 transpedicular NADERI AND T.

8 MERTOL230J Spinal Disord & Techniques, Vol. 15, No. 3, 2002toms of Lumbar spinal stenosis. In the years thereafter,similar cases of combined spinal stenosis were reported byothers (3 5).One of the most important aspects of combined stenosisis the clinical picture. Simultaneous symptomatic cervicaland Lumbar spinal involvement commonly results in acombination of upper and lower motor neuron findings,gait imbalance, and neurogenic claudication. Dagi et al.(4) called this condition tandem spinal stenosis, reportingthe incidence of symptomatic tandem spinal stenosis to be5% to 25%. They found that 7 of 12 cases reported byTeng and Papatheodorou (8) as well as 3 of 20 patientsreported by Wilson (9) had tandem spinal stenosis. Bothof our cases presented with symptoms of both Cervical andlumbar spinal stenosis, therefore indicating decompres-sion of both imaging findings have been shown in asymp-tomatic adults by using discography (37%) (10), myelog-raphy (24%) (11), computed tomography (36%) (12), andMRI (8,13 17).

9 The fact that the prevalence of radiologicspinal stenosis is higher than the prevalence of symptom-atic spinal stenosis dictates that the surgeon decide aboutthe indication of Surgery in patients with an accompanyingradiologic stenosis without clinical signs. It is our opinionthat the presence of an accompanying radiologic spinalstenosis without neurologic symptoms does not constitutean indication for decompression. The most important in-dication for two-level Surgery is the presence of symptomsat both cases with symptomatic two-level spinal stenosis,another surgical consideration is the choice of which levelshould be decompressed first. Most physicians prefer todecompress one level in each session. We prefer to de-compress the Cervical spine before the Lumbar spine be-cause Cervical decompression may also provide someimprovements in Lumbar symptoms.

10 This is because thelumbar neural fibers may also be under compression inthe Cervical spondylotic Benini (3) reported that a Simultaneous de-compression in such cases is impossible, Dagi et al. (4)were the first surgeons who performed a simultaneouscervical and Lumbar spinal decompression in four performed a Simultaneous decompression and fixationof both levels. The reasons for Simultaneous surgeries inour patients include the presence of symptomatic stenosesof both Cervical and Lumbar spine and the patients generalcondition, necessitating a one-session and short-lastingsurgery ( , a Simultaneous procedure by two surgeryteams to reduce the surgical duration in patients with arisky general condition).In summary, the surgical considerations in patients withsymptomatic combined spinal stenoses include the defini-tion of the disease, the indication for one-level or two-level Surgery , and the choice of Surgery in one or twosessions, dictating a detailed neurologic examination andcareful neuroradiologic investigation.