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30-AUGUST-2008  RAWDA HASHEM JABER  46 YEARS  PCD C6-7 WITH RIGHT FORAMINAL OCCLUSION.

Anamnesis:

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The patient came to the clinic 04-April-2005 complaining of neck and left shoulder pain for nine months with exacerbation last month with cephalic syndrome.

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MRI performed 01-July-2004 showed PCD C5-6 with left partial foraminal occlusion.

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On examination: the patient had weak extension of the left hand  the weak left triceps muscle 4/5. The patient had pain when looking up and bending the head to the left with agonizing pain with sleep disturbances due to pain.

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The patient managed herself conservatively and was in good condition, until she came 28-August-2008 with severe agonizing neck pain for 2 months shooting to the right upper limb.

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MRI of the cervical spine performed 28-August-2008 showed de novo PCD C6-7 with occlusion of the right foramen and shrinkage of the previous disc at C5-6.

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On examination: the patient in agonizing pain, preventing her from sleep for several days. There is weak grip and extension of the right hand and the right triceps muscle -4/5. There is numbness of the entire right hand with hypalgesia of the median territory of the right hand.

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Anterior approach with discectomy of C6-7 was done under image-intensifier. The extruded material was removed in several pieces.

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Routine closure of the wound and smooth postoperative recovery with normalization of the power of the right upper limb.

Comments

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The patient was treated conservatively 2005 for the first extrusion of C5-6 and the extrusion disappeared in the new performed MRI.

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Surgery as in this case was the only option, since she was not responding to conservative measures and she was urging for surgery.

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Simple discectomy is the preferred choice of treatment, since there is no signs of instability.

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