551 - Cervical Disk Replacement for Disc Protrusion with Cervical Stenosis and Radiculopathy

Case Diagnosis: C4-5 Disc Protrusion with Cervical Radiculopathy

Case Description: 34 year old female who presented with right arm and neck pain following a flight from Italy. Her pain was exacerbated with neck flexion.

MRI revealed a large (8 x 4 x 10mm), C4-C5, central disc protrusion which moderately compressed the ventral cord, without cord signal abnormality.

Conservative treatments, including home exercises, electrical stimulation, NSAIDs, and a medrol dose pack provided no relief. A C7-T1 interlaminar epidural steroid injection was then performed with exacerbation of pain. A decision was made to pursue C4-C5 anterior cervical disk replacement with immediate relief of pain.

Discussions: Cervical disc herniations have the potential to resorb, often prompting initial conservative management. However, central disc herniations, without extrusion, and an intact posterior longitudinal ligament are less likely to resorb, as they are not exposed to systemic circulation and recognized as a foreign body. Such cases may require surgical intervention.

Traditionally, surgical management with anterior cervical discectomy and fusion (ACDF) has been employed. However, ACDF limits spinal mobility and has been associated with an increased risk of adjacent segment disease. Anterior cervical disc arthroplasty/replacement (ACDA), has gained popularity over the past decade as a way to maintain range of motion and reduce adjacent segment disease.

Conclusions: Central disc protrusions with an intact posterior longitudinal ligament are less likely to be resorbed. Thus, these patients may be more likely to fail conservative management.

For these patients, anterior cervical disc arthroplasty (ACDA) may be considered as an alternative to anterior cervical discectomy and fusion (ACDF). By replacing the native disc material with an artificial disc, cervical mobility is preserved in an attempt to reduce the adjacent segment stress associated with cervical fusions. This has been supported in the literature with reduced rates of significant adjacent segment pathology and adjacent level surgery at 10-year follow-up.