MARY K
Networker
I always get nervous when one of my surgeon's circles a level 5 new patient and I agree. Could someone please verify that I am not crazy?
CC: Inability to ambulate,numbness and tingling in both hands and both legs
HPI: This patient was diagnosed with neuropathy of unknown etiology. He ultimately saw a neurologist and was told that he has issures in the cervical spine. In 2008 the patient underwent a percutaneous hydrodiscectomy in the lumbar spine. He is not sure what level. Unfortunately, for the past year now he cannot ambulate. He cannot walk for more than 100 feet before his legs start to give out and lately his arms have felt weak and he has been unable to do fine motor skills. He has a hard time coordinating movement. He connot hold a glass. He had EMG's done which are negative for carpal tunnel syndrome, the patient reports. He was told that he needs cervical spine intervention. He had a MRI done of the cervical spine which I have personally reviewed films and it shows severe spinal stenosis with gliosis at C5-C6 and instability with anterior subluxation. he also has prominence facet joint hypertrophy posteriorly.He does have additional spondylosis at other locations including C3-C4, but thate are no ischemic changes. With respect to the lumbar spine MRI, the patient has severe spinal canal, the patient has severe spinal canal stenosis at L3-L$ with mild to moderate foraminal stenosis at L$-L5 and L5-S1. The patient's biggest comlaint today is the cervical spine and loss of function in his hands.
PMH/PSH,MEDICATIONS/ALLERGIES/SOCIAL HISTORY/FAMILY HISTORY: Are reviewed on the intake sheet.
ROS:All systems reviewed are negative.
PHYSICAL EXAMINATION:The patient is a well-developed,well-nourished male in no apparent distress. The patient amblates about the examination room without difficutly. The patient is awake,alert and oriented x3. height,weight and blood pressure are recorded on the face sheet. Respirations are non-labored. Heart: deferred. Lunges
eferred. There is no lymphedema in upper/lower extremity. Examination of the cervical spine reveals no tenderness to deep palpation. There is no evidence of gross instability. Trunk strength is well maintained. Forward flexon and extension are. There is no evidence of swelling in the spinal region. Fine motor coordination for upper and lower extremities. Bilateral shoulder, elbow and wrist range of motionare full. Grip strength is 5/5. Biceps,triceps are 5/5. The pelvis appears to be stable in the standing position. Trendelenburg test is negative. Reflexes are 2+ and symmetrical at the knee and the ankle. There is no clonus. Sensation is intact in all dermatomes tested. SKin is without lesions. Vasclar examination is satisfactory in both upper and lower extremities. Straight leg raise testing is negative bilaterally. In the seated postition bilateral hip,knee, ankle range of motion are smooth and nontender.
PLAN: I had a detailed conversation with the patient. He is suffering from severe claudication, but also severe spinal cord compression and gliosis. The C5-C6 gliosis is a secondary consequence of the pressure. I discussed with the patient the material reisks,benefits and alternatives of anterior cervical discectomy at C5-6 with the possibility of a stage posterior decomopression at the facet joint at C5-C6 and instrumentation for both levels. I explained to the patient that I don't feel comfortable doing an anterior/posterior cervical spine the same day because of respiratory compromise which can occur. In addition, an anterior C5-C will be done and then repeat imaging will be done to look for any evidence of residual buckling posteriroly. In addition, ultimately he is going to require interventionat L3-L4 for the severe stenosis. This maybe in the for of posterior decompression or direct lateral stabilization. The patient is quite miserable because he can't do anything. He is relatively young, but is unable to walk more than 100 feet because of significant arm and leg symptoms. The possiblilty of infecton, DVT,persistent pain, esophageal injury, catastrophic neurologic comppromise, ischemic insult to the spinal cord,paraplegia,paraparesis,cauda equina syndrome were discussed. The possibility of staging it posteriorly as well at a later date and ultimately the need for decompression of the lumbar spine as he does have significant clauditory symptoms as well. The patient wants to get this set-up as soon as possible. We will schedule the surgery for ACDF C5-C6 with spinal cord monitoring sometime after the first of the year. The patient was advised to refrain from all violent or high speed activities which could cause any type pf whiplash injury to the cervical spine.
CC: Inability to ambulate,numbness and tingling in both hands and both legs
HPI: This patient was diagnosed with neuropathy of unknown etiology. He ultimately saw a neurologist and was told that he has issures in the cervical spine. In 2008 the patient underwent a percutaneous hydrodiscectomy in the lumbar spine. He is not sure what level. Unfortunately, for the past year now he cannot ambulate. He cannot walk for more than 100 feet before his legs start to give out and lately his arms have felt weak and he has been unable to do fine motor skills. He has a hard time coordinating movement. He connot hold a glass. He had EMG's done which are negative for carpal tunnel syndrome, the patient reports. He was told that he needs cervical spine intervention. He had a MRI done of the cervical spine which I have personally reviewed films and it shows severe spinal stenosis with gliosis at C5-C6 and instability with anterior subluxation. he also has prominence facet joint hypertrophy posteriorly.He does have additional spondylosis at other locations including C3-C4, but thate are no ischemic changes. With respect to the lumbar spine MRI, the patient has severe spinal canal, the patient has severe spinal canal stenosis at L3-L$ with mild to moderate foraminal stenosis at L$-L5 and L5-S1. The patient's biggest comlaint today is the cervical spine and loss of function in his hands.
PMH/PSH,MEDICATIONS/ALLERGIES/SOCIAL HISTORY/FAMILY HISTORY: Are reviewed on the intake sheet.
ROS:All systems reviewed are negative.
PHYSICAL EXAMINATION:The patient is a well-developed,well-nourished male in no apparent distress. The patient amblates about the examination room without difficutly. The patient is awake,alert and oriented x3. height,weight and blood pressure are recorded on the face sheet. Respirations are non-labored. Heart: deferred. Lunges
eferred. There is no lymphedema in upper/lower extremity. Examination of the cervical spine reveals no tenderness to deep palpation. There is no evidence of gross instability. Trunk strength is well maintained. Forward flexon and extension are. There is no evidence of swelling in the spinal region. Fine motor coordination for upper and lower extremities. Bilateral shoulder, elbow and wrist range of motionare full. Grip strength is 5/5. Biceps,triceps are 5/5. The pelvis appears to be stable in the standing position. Trendelenburg test is negative. Reflexes are 2+ and symmetrical at the knee and the ankle. There is no clonus. Sensation is intact in all dermatomes tested. SKin is without lesions. Vasclar examination is satisfactory in both upper and lower extremities. Straight leg raise testing is negative bilaterally. In the seated postition bilateral hip,knee, ankle range of motion are smooth and nontender.PLAN: I had a detailed conversation with the patient. He is suffering from severe claudication, but also severe spinal cord compression and gliosis. The C5-C6 gliosis is a secondary consequence of the pressure. I discussed with the patient the material reisks,benefits and alternatives of anterior cervical discectomy at C5-6 with the possibility of a stage posterior decomopression at the facet joint at C5-C6 and instrumentation for both levels. I explained to the patient that I don't feel comfortable doing an anterior/posterior cervical spine the same day because of respiratory compromise which can occur. In addition, an anterior C5-C will be done and then repeat imaging will be done to look for any evidence of residual buckling posteriroly. In addition, ultimately he is going to require interventionat L3-L4 for the severe stenosis. This maybe in the for of posterior decompression or direct lateral stabilization. The patient is quite miserable because he can't do anything. He is relatively young, but is unable to walk more than 100 feet because of significant arm and leg symptoms. The possiblilty of infecton, DVT,persistent pain, esophageal injury, catastrophic neurologic comppromise, ischemic insult to the spinal cord,paraplegia,paraparesis,cauda equina syndrome were discussed. The possibility of staging it posteriorly as well at a later date and ultimately the need for decompression of the lumbar spine as he does have significant clauditory symptoms as well. The patient wants to get this set-up as soon as possible. We will schedule the surgery for ACDF C5-C6 with spinal cord monitoring sometime after the first of the year. The patient was advised to refrain from all violent or high speed activities which could cause any type pf whiplash injury to the cervical spine.