Patient Case Study #1: Cervical Disc Herniation

History

48 year-old right-hand dominant woman shipping manager who presented with a 2-month history of severe left arm pain and weakness to the degree that she could not work. She had tried medications and injections in her neck which provided little relief.

Examination

She had significant weakness in her left triceps as well as her left wrist flexors (bending the wrist forward). She had dense numbness involving her left index finger and middle finger.

Images

Before treatment x-ray shows mild arthritis, but the MRI shows a large disc herniation on the left at the C6-C7 level impinging on the spinal cord and nerve root.

Diagnosis

Disc herniation C6-C7 affecting function of the nerve.

Selected Treatment

C6-C7 anterior cervical discectomy and fusion (ACDF) involving removal of the disc from the front of the neck, replacement with bone graft, and placement of a plate for stabilization of the level.

Outcome

Patient had immediate and complete relief of her arm pain and has regained full strength and sensation in her arm 3 months after surgery.