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 Table of Contents  
CASE REPORTS
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 214-217

Fractured cervical facet osteophyte causing acute traumatic myelopathy: Case report


Spine Department, Nanavati Hospital, Mumbai, India

Date of Submission20-May-2020
Date of Decision15-Jul-2020
Date of Acceptance01-Dec-2020
Date of Web Publication24-May-2021

Correspondence Address:
Bharat K Patel
Spine Department, Department of Spine Surgery, Nanavati Super Speciality hospital, S. V. Road, Vile Parle west, Mumbai, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/isj.isj_44_20

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  Abstract 

A 52-year-old gentleman presented with acute onset quadriparesis of ten days duration after a trivial fall. Both extremities had grade-2 power. Bilateral hand grip was poor with interossei weakness. The sensation was reduced below C6 with positive Lhermitte’s sign. Deep tendon reflexes were exaggerated except absent bilateral biceps jerk. The bowel and bladder had urgency and frequency. Neck movements were terminally painful. CT and MRI showed a floating bony spicule adjacent to left C5-6 facet joint encroaching the spinal canal causing cord compression. A focal left C5 hemi-laminectomy and foraminotomy were performed. A onecm floating bony spicule adjoining to left C5-6 facet joint was excised. Biopsy ruled out osteochondroma and synovial cyst. The power improved to grade-4 in both extremities with moderate grip and he became dependent ambulatory within three months of surgery. At the end of two years, he recovered almost completely with residual mild left-hand grip weakness.

Keywords: Cervical spondylotic myelopathy, facet arthropathy, facet fracture, fractured osteophyte


How to cite this article:
Patel BK, Bapat MR, Upadhyay A. Fractured cervical facet osteophyte causing acute traumatic myelopathy: Case report. Indian Spine J 2021;4:214-7

How to cite this URL:
Patel BK, Bapat MR, Upadhyay A. Fractured cervical facet osteophyte causing acute traumatic myelopathy: Case report. Indian Spine J [serial online] 2021 [cited 2021 Dec 4];4:214-7. Available from: https://www.isjonline.com/text.asp?2021/4/2/214/316664




  Introduction Top


Cervical spondylotic myelopathy is often aggravated by trivial trauma. In such a scenario, the spinal cord suffers from a combination of pincer forces contributed by hard disc, ligamentum flavum, and facet arthropathy.[1],[2],[3] Surgical decompression is the preferred treatment in most cases. Isolated facet arthropathy causing acute spinal cord injury is uncommon and a fractured osteophyte is an even rarer cause of myelopathy. We report a traumatic facet osteophyte fracture that caused myelopathy in a middle-aged patient with a normal sized canal.


  Case Report Top


A 52-year-old gentleman presented with acute onset quadriparesis of ten days duration. After a trivial fall, there was a complete loss of power in all extremities and he was shifted to a nearby hospital. Conservative treatment that included neck immobilization in a rigid collar and intravenous steroids was given. After the spinal shock, partial and non-functional recovery of power was observed that plateaued after one week. He was shifted to our institute for further management ten days after the fall. At presentation, the detail neurological examination revealed grade-2 power in upper and lower extremities as per the Medical Research Council (MRC) grade. He had bilateral poor hand grip with interossei weakness. Neck movements were terminally painful. There was no radiculopathy. Sensation was reduced below C6 dermatome. There was spasticity and Lhermitte’s sign was positive. Deep tendon reflexes (DTR) in lower extremities were exaggerated with positive Babinski sign. In upper extremities, DTR was exaggerated with Hoffman’s sign except absent bilateral biceps jerk. The bowel and bladder functions (sensation and void) were normal except for urgency and frequency. Higher mental function was normal. Spinal cord injury was graded by American spinal injury association impairment (ASIA) scale and was “ASIA C.” The pre-operative modified Japanese Orthopedic association (mJOA) score was six. Detailed radiological investigations were advised. MRI showed a left C5-6 facet joint hypertrophy with an intra-spinal cystic mass in T2 images [Figure 1]. The spinal cord showed myelomalacia and was displaced to the right. The posterior soft tissues were normal. The rest of the cervical spine showed mild degenerative changes. The flexion-extension x-rays (supervised) did not reveal instability. The Pavlov’s ratio was 0.8–1. The CT scan showed a floating bony spicule adjacent to the left C5-6 joint osteophyte encroaching into the spinal canal [Figure 2]. The joint space was reduced with arthritic changes. The contralateral joint showed minimal changes. The somatosensory evoked potentials showed delayed posterior column conduction. A targeted C5 hemi-laminectomy with foraminotomy was done [Figure 3]. A loose round onecm ossicle was identified in the canal adjoining the joint and was excised [Figure 4] and [Figure 5]. The encroaching osteophytic edge of the joint was trimmed.
Figure 1: T2 sagittal (A) and axial (B) images of MRI showed an intra-spinal cystic mass arising from left C5-6 facet joint encroached to spinal canal and displaced cord to right side

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Figure 2: Sagittal (A), coronal (B) and axial (C) images of CT scan revealed a floating bony spicule adjacent to left C5-6 facet joint osteophyte encroaching into the spinal canal

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Figure 3: Post-operative sagittal (A) and axial (B) images of CT scan showed C5 left focal hemi-laminectomy and foraminotomy. A calcified intra-spinal mass was completely removed and an edge of the osteophyte from joint was trimmed

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Figure 4: Intra-operative microscopic image confirmed a loose calcified mass (black arrow) in the canal adjoining the joint. (SC = spinal cord)

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Figure 5: A onecm round loose bony ossicle was identified in canal and excised

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The rehabilitation program was started next day after surgery. The program included joint mobility, muscle strengthening, motor skill development, breathing exercises, and pressure-sore prevention. He was discharged on the fifth post-operative day. The neurological status was the same at discharge. The motor power improved by one grade in both extremities (MRC 3) except hand grips at suture removal after 2 weeks of surgery. At 3 months, he became ambulatory with a stick having clumsiness of gait and was able to close his grip but lacked useful strength (mJOA score: 8). Both extremities had grade-4 motor power. At 9 months, he became ambulatory without stick with mild clumsiness but requires support during step climbing. Grip strength improved significantly with mild restriction of fine function (writing/buttoning). Bowel and bladder function returned to normal. Sensation was normal in both extremities. Modified JOA score was 14. He was almost independent for activities of daily living (dressing, washing and eating) and resumed his desk job with minor modification of work. Patient showed almost complete neurological recovery with mild left hand residual grip weakness at 2-year follow up (ASIA-D/E). Modified JOA score improved to 17. Histopathology ruled out osteochondroma and synovial cyst.


  Discussion Top


Degenerative stenosis causes a dynamic pincer compression of the spinal cord due to reduction of the canal circumference with neck movements.[4],[5] Posteriorly, the hypertrophied facets with buckling of the ligamentum flavum contribute to the compression. Superimposed trauma causes deleterious pressure changes within the spinal cord due to sharp rise in pressure.[6] Facet fractures with intra-canal fragments occur when the facet joint anatomy is disrupted by a violent disrupting force.[7] In our case, the facet anatomy was maintained. There was no evidence of instability. Probably an extension force locked the facet, thereby fracturing the osteophyte. The intra-canal fragment separated from the facet osteophyte and caused a transient pincer effect on the spinal cord. On the MRI, a mass effect with T2 hyperintensity raised the doubt of a facet synovial cyst. One of the theories proposed is a sudden mechanical stress that causes synovial herniation particularly in arthritic joints.[8] This was, however, refuted in the CT scan. Facet cysts are usually seen in the atlantoaxial region. A broken osteochondroma was also ruled out by the absence of pedicle and a cartilage cap.[9] In our case, the biopsy ruled out osteochondroma and synovial cyst. The patient was asymptomatic before his fall. The neck pain and spasm at presentation was mild. This was because the facet anatomy remained normal and there was no nerve root impingement. The predominant effect was akin to spinal tumor syndrome presenting as myelopathy. The neurology of the patient improved to normal functional level at final follow up. He resumed his desk job with minor modification of work at nine months of follow up. In our case, there was no change in socioeconomic status of the patient after surgery as per modified Kuppuswamy scoring system described by Goel et al.[10] The socioeconomic status had no significant impact on overall clinical outcomes. In the author’s opinion, a similar case has never been reported in the English literature.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fengbin Y, Deyu C, Xinwei W, Yu C, Jinhao M, Xinyuan L, et al. Trauma-induced spinal cord injury in cervical spondylotic myelopathy with or without lower cervical instability. J Clin Neurosci 2013;20:419-22.  Back to cited text no. 1
    
2.
Chang V, Ellingson BM, Salamon N, Holly LT. The risk of acute spinal cord injury after minor trauma in patients with preexisting cervical stenosis. Neurosurgery 2015;77:561-5.  Back to cited text no. 2
    
3.
Machino M, Ando K, Kobayashi K, Morozumi M, Tanaka S, Ito K, et al. Differences in clinical outcomes between traumatic cervical myelopathy and degenerative cervical myelopathy: A comparative study of cervical spinal cord injury without major bone injury and cervical spondylotic myelopathy. J Clin Neurosci 2019;70:127-31.  Back to cited text no. 3
    
4.
Baron EM, Young WF. Cervical spondylotic myelopathy: A brief review of its pathophysiology, clinical course, and diagnosis. Neurosurgery 2007;60:S35-41.  Back to cited text no. 4
    
5.
Lebl DR, Hughes A, Cammisa FP, O’Leary PE. Cervical spondylotic myelopathy: Pathophysiology, clinical presentation and treatment. HSSJ 2011;7:170-8.  Back to cited text no. 5
    
6.
Yoo DS, Lee SB, Huh PW, Kang SG, Cho KS. Spinal cord injury in cervical spinal stenosis by minor trauma. World Neurosurg 2010;73:50-2.  Back to cited text no. 6
    
7.
Kepler CK, Vaccaro AR, Chen E, Patel AA, Ahn H, Nassr A, et al. Treatment of isolated cervical facet fractures: A systemic review. J Neurosurg Spine 2016;24:347-54.  Back to cited text no. 7
    
8.
Costa F, Menghetti C, Cardia A, Fornari M, Ortolina A. Cervical synovial cyst: Case report and review of literature. Eur Spine J 2010;19:S100-2.  Back to cited text no. 8
    
9.
Yakkanti R, Onyekwelu I, Carreon LY, Dimar JR II. Solitary osteochondroma of the spine-a case series: Review of solitary osteochondroma with myelopathic symptoms. Global Spine J 2018;8:323-39.  Back to cited text no. 9
    
10.
Goel SA, Modi HN, Dave BR, Patel PR, Patel R. Socioeconomic impact of cervical spinal cord injury operated in patients with lower income group. Indian Spine J 2018;1:46-50.  Back to cited text no. 10
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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