Case 1
Clinical presentation
The first patient was an Asian male, 61, presenting left lower limb burning in the last 5 years. He also felt nack pain, upper limb numbness, and girdle chest sensation. There was no hypertension, diabetes, and nephropathy history. Also, he did not have a history of hepatitis, tuberculosis, trauma, blood transfusion, poisoning, and penicillin anaphylaxis.
On examination, he could walk on his own but staggering. The cervical spine motion range was normal, but the neck and shoulder muscles were tense. He also presented left body hypoesthesia below the nipple. The main left limb muscles strengths were slightly decreased, and the right ones were normal: (left biceps brachii 4/5, triceps brachii 4/5, dorsal forearm 4/5, volar forearm 4/5, hand grasp 4/5); (right biceps brachii 5/5, triceps brachii 5/5, dorsal forearm 5/5, volar forearm 5/5, hand grasp 5/5); (left quadriceps femoris 4/5, tibialis anterior 4/5, gastrocsoleus 4/5, flexor longus 4/5); (right quadriceps femoris 5/5, tibialis anterior 5/5, gastrocsoleus 5/5, flexor longus 5/5); Bilateral Eaten signs (-), Spurling signs (+), Hoffman signs (+), Babinski signs (+), patellar clonus (+++), ankle clonus (+++); Bilateral knee-tendon reflex (++) and Achilles tendon reflex (++).
Radiologic evaluation
MRI and coronal and sagittal Computerized Tomography (CT) showed cervical disc herniation in cervical 3/4, 4/5, 5/6; and cervical 4/5; 5/6 level spinal cord compression (Fig. 1A-D).
Treatment
An anterior cervical surgery, C4/5, 5/6 discectomy, and zero-p interbody fusion were performed.
Outcome and follow-up information
After surgery, CT showed that the herniated discs in C4/5 and C5/6 were removed, and the fusion cage was in a good position (Fig. 2A-C). On the first day after the operation, the left lower limb burning was relieved, and upper limb numbness almost disappeared. One month later, he had no complaints about left lower limb burning and upper limb numbness in the phone call back.
Case 2
Clinical presentation
The second patient was an Asian female, 40, who came to our hospital due to left lower leg and foot numbness and pain in the last 6 months. She also felt headache, dizziness, right ring finger numbness, and right heel pain. She had diabetes for 6 years but in good control. She did not have a history of hypertension and nephropathy, no hepatitis, tuberculosis, trauma, blood transfusion, poisoning, and penicillin anaphylaxis. She did not regularly drink alcohol and never smoked. On examination, she could normally walk on her own. The cervical spine motion range was normal, but the neck and shoulder muscles were tense. She also had lumbar percussion pain. The left thigh circumference was about 1.5 cm smaller than that of the opposite side. The left thigh sensation was decreased in the front and back sides, and the left leg and sole sensation were also decreased, especially the sole. The left limb main muscles strength was slightly decreased. Additionally, the right heel had tenderness. The pathological and physiological reflexes were normal.
Radiologic evaluation
MRI showed cervical disc herniation (cervical 4/5, 5/6) and cervical 5/6 level left spinal cord compression (Fig. 3A-C). Cervical 5 had vertebral hemangioma and left ligamentum flavum thickening at the T2/3 disc level.
Treatment
An anterior cervical surgery, C4/5, 5/6 discectomy, zero-p interbody fusion, and a C5 cement filling was performed.
Outcome and follow-up information
After surgery, the CT showed that C4/5, 5/6 spinal cord compression was relieved (Fig. 4A-C). On the first day after the operation, the left lower leg and foot numbness and pain were relieved, the right heel pain disappeared. The left limb's main muscles strength was recovered. The headache, dizziness, right ring finger numbness were slightly relieved. One month later, she had no complaints about lower limb numbness and pain in the phone call back.
Case 3
Clinical presentation
The third patient was an Asian male, 34, who came to our hospital due to right lower limb numbness and pain in the last 3 months. He had no history of hypertension, diabetes, and nephropathy; no hepatitis, tuberculosis, trauma, blood transfusion, poisoning, and penicillin anaphylaxis. He did not drink alcohol regularly and never smoked.
On examination, he could normally walk on his own. The right body hypoesthesia below the nipple and right lower leg temperature sensation declined. The limbs muscle tension was normal, and there was no obvious atrophy and fine motor disorder. The cervical spine motion range was normal, but the cervical spine curvature was straight, and the neck and shoulder muscles were tense. The main limbs muscles' strength was normal. The pathological and physiological reflexes were also normal.
Radiologic evaluation
Magnetic resonance imaging (MRI) showed cervical disc herniation (cervical 5/6); cervical 5/6 level left spinal cord compression and degeneration (Fig. 5B, C). The whole spine MRI showed no thoracic and lumbar abnormalities (Fig. 5A).
Treatment
An anterior cervical C5/6 surgery, a discectomy, and a zero-p interbody fusion were performed.
Outcome and follow-up information
After surgery, the MRI showed that the left spinal cord C5/6 compression was relieved (Fig. 6A, B). After the operation, right body numbness and pain below the nipple cleared up and the right lower limb numbness and the pain was relieved. Three months later, the MRI showed that the spinal cord degeneration had recovered, and the right lower limb numbness and pain were almost relieved.