When the disease is in its chronic form -as it usually happens after spine surgery or following the acute and subacute phase of radiculitis from disc herniation that had been undertreated with conservative therapy- neuroplasty (adhesiolysis) with Racz catheter is indicated.
The American Society of Interventional Pain Physicians (ASIPP) published evidence-based guidelines for invasive techniques in the management of chronic spinal pain.
According to these guidelines, there is strong evidence indicating the efficacy of neuroplasty with corticosteroids in the short and long-term control of pain in refractory radiculopathy and neuropathic spinal pain.
The clinical history, physical examination, and imaging is consistent with extensive destruction of the lumbar spine extending over three vertebral segments with associated epidural abcess necessitating surgical decompression and fusion. An epidural abscess may present rapidly with neurological compromise. Prognosis improves with prompt decompression, but only 18% of patients with frank abscess and 23% of patients with paralysis completely recover after decompression.
Hadjipavlou et al report in their Level 4 study that leukocyte counts were elevated in % of spondylodiscitis cases. The erythrocyte sedimentation rate was elevated in all cases of epidural abscess.
The article by Harrington et al states that the surgical indications for an epidural abcess include: unsuccessful antibiotic treatment after 6 weeks, vertebral deformity or instability, neurological deficit, MRI showing > 50% compression of thecal sac, and depressed host immune response.
Illustration A shows radiographs following anterior debridement, corpectomy, fibular strut grafting, and Kaneda instrumentation.
The patient's clinical picture is consistent with cervical spondylosis. Minimal symptoms without hard evidence of gait disturbance or pathologic reflexes warrant nonoperative treatment, making physical therapy the correct answer.
Cervical spondylosis is a process that results in disc degeneration and facet arthropathy. Clinical manifestations may range from axial neck pain to profound muscle weakness and difficulties ambulating. It is generally agreed upon that patients with neuroradiologic evidence of spinal cord compression but no signs of myelopathy should be managed non-operatively. Initial management should consist of physical therapy, NSAIDs, and a cervical collar for comfort.
Boden and McCowin et al. describe the prevalence of abnormal cervical spine MRI findings in asymptomatic patients. 19 percent of asymptomatic patients were found to have abnormal scans. The most common finding in subjects less than 40 years old was a herniated disc, while the most common finding in subjects greater than 40 years of age was foraminal stenosis.
Kadanka and Mares et al. provide a prospective, randomized study comparing conservative and operative treatment of mild and moderate forms of spondylotic cervical myelopathy. At the 3-year follow-up period, there were no significant differences between the surgical and conservative treatment groups.
Figure A shows a lateral radiograph with loss of cervical lordosis and mild degenerative changes at C5-6, C6-7. Figures B shows a sagittal MRI with mild stenosis and loss of cervical lordosis. Figure C shows the axial MRI with left-sided foraminal stenosis at C5-6.
Answers 1-4: non-operative management is recommended in this situation.