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Dr. Schupeck,

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this is a 47-year-old woman who's had anterior neck

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surgery and now has cervicalgia or neck pain.

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It doesn't say anywhere that she's had arm pain.

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So, let's start out by having you describe

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what was done to her at the C5-6 level.

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Okay, well, here we are at C5-6.

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So this would be the best operation, neurosurgery,

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which is anterior cervical decompression and fusion ACDF.

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And the reason it's a great operation is because it

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really works. Now, this one.

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So the question is,

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when you see an ACDF,

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it's just like any other case that

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we're looking at neurosurgically.

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We want to see whether the goals of surgery were achieved.

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First of all. So what are the goals?

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Decompression and stabilization. Okay.

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So we got stabilization.

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So decompression got bony bridging stabilization.

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Bony bridging, right. And the question is,

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are we decompressed? So I guess we'll pull down the axial.

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There you go.

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So we're decompressed up high.

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We'll talk about that in a little bit.

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But down at the level of the surgery, are we decompressed?

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Yeah.

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So the framing will look pretty good and the canal looks good.

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The frame and are wide open.

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The canal looks good.

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Here's your prosthetic disc, so to speak.

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Right, so it's solid. Okay.

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We can see there's bony bridging.

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The other question is what's the status of the

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instrumentation? So there is instrumentation here,

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and you want to make sure is there a screw sticking out

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into the esophagus? That used to happen commonly.

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The newer plates have locking mechanisms so much

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less frequently. But that looks pretty good.

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It's well applied. Okay.

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It's not like sticking it forward into any soft tissues.

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So at this level looks pretty good.

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So this is not going to be an ongoing source

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of either radiculopathy or neck pain.

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So we're going to move on elsewhere.

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Well, here's the plate. Right.

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And I guess these are screws right there.

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And this is probably your disclaimer BMP,

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your implant with some BMP in it.

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Yeah, this is probably a prosthetic implant,

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and then bone can be put in it.

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Bone morphogenetic protein. Now,

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bone morphogenetic protein has had some problems a lot less

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frequently used in the cervical spine than it was,

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but still somewhat I didn't know that used.

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Whatever they did, it worked.

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They got a good solid fusion.

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So as they say, this level,

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we can give them a good pass on that.

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Worked fine. But once you fuse a level,

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changes the dynamics above and below,

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so they got to move on to there to see what our current

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problem is. Can you address an issue for me as a radiologist?

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The alignment,

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it looks like there's kind of almost like

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a lordotic let me just use a pen here.

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Almost like a lordotic scenario here.

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And it looks like the front.

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Of the vertebrae are kind of sucked in almost.

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Right. Is that normal? Well, it's not normal.

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And it is important in neck pain, right?

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Because you have a loss of Sagittal balance.

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Sagittal balance is a term you're going to hear used.

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There's a lot of emphasis on it recently.

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Restoration of Sagittal balance for problems like pain,

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but also later changes that it alters

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the mechanics above and below.

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So there is a reversal of the cervical lordotic curve here.

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It might have been had a reversal preoperative.

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We don't know exactly what it looked like at that point,

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but there's no question that you got this fuse fine,

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but you got a sublux here.

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Sublux here. Okay.

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So you do have a problem of segmental instability

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above and below. That's correct.

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And segmental instability can be a cause of neck pain.

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Now, what about the medial lateral?

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You were talking briefly about the curvature and the coronal

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projection before we started our vignette here,

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and it does look like it's a little crooked.

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Right.

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Cervical thoracic scoliosis is something you should

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pay attention to and put in the report,

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because that has a lot to do with one.

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Can that be a cause of neck pain?

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Yes. Two has a lot to do with how you interpret the study.

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Meaning if it's coming one way or the other,

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the frame and are going to look different to you,

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you may analyze them a little differently.

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The instrumentation has to go on in a different way.

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So it's important to you and important to the surgeon.

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Well,

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I wouldn't have paid attention to that years ago

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until I met you, and I'm grateful for that.

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Another interesting aspect of this case

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is the cranio cervical junction.

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It looks like the patient has had a suboccipital craniectomy,

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I guess for chiari or for tonsillar ectopia.

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And there is a retroflex dens,

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which allegedly is one of the bone abnormalities

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associated with Chiari malformation.

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Could the patient's neck pain be coming from this locus here?

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Now, the atlantoaxial interval is maintained,

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so we don't have frank instability there.

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And actually,

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these people usually do better than you would think.

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You think? Well, if you do,

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it's because this has not only a suboccipital craniectomy,

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but probably at least a partial C1 laminectomy maybe,

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or there's a little button here,

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because you often do take off C1

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with the Chiari. So instability is not often a problem.

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But in this case, I think you've had some settling.

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The dens is a little bit elevated.

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There's a little bit of ventral pressure there.

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Okay. So if you measure the clivoaxial angle,

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which is normally greater than 150 degrees,

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it might be a little less than that.

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We're not measuring it right here.

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So there's a little bit of platybasia here.

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Yes. I don't want to get into angles too much,

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but the platybasia that you're referring to

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is the flat appearance of the clivus here.

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And we'll talk about lines when we get into

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cranio-cervical junction abnormalities.

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But it looks like they've decompressed the patient.

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Yeah, so you're right. They did do a C1.

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One laminectomy. C1 laminectomy on the axial projection,

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and it doesn't look like they took too much bone off

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because they want to stay below the equator,

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decompress the foramen magnum.

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But don't go too high, because then the cerebellum drops down.

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The cerebellum drops down,

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and you can get something called cerebellar ptosis.

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Right? So you don't want to take the bone off up here,

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right? You want to take it off.

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They took it off down here.

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But if you go to the equator up too high,

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then you've got a big problem.

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That's hard to correct. Right.

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So in summary, basically, we've got an AC DNF.

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They have successfully fused the C56 level.

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Whoops. Let me just get you out of this.

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Yeah, they've successfully fused the C56 level.

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The pedicle screws are in decent position.

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They've done a C1

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decompression posteriorly. They've done occipital craniectomy.

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They've relieved what allegedly was a Chiari malformation.

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And now I know you're drilling for the facets as a potential

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cause, right? So that might be the cause.

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Neck pain right there. That might be your cause right there.

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There you go. There is some swelling right there.

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There's a little edema within the facet joint itself.

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And that probably is the most likely cause of the neck pain

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because it looks like it was a successful

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other than the curvature. Right.

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I would say there's several reasons for neck pain.

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The alignment is one. Cervical thoracic scoliosis is another.

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The subluxation segmental instability is another.

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But that hot facet, if it's on the appropriate side,

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I bet is candidate number one.

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Great. Well, that's our discussion of ACDF.

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You can see there are multiple potential causes for the

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patient's neck pain, and we'll move on to another case.