Upper cervical cord compression due to a C-1 posterior arch in a patient with ossification of the posterior longitudinal ligament and a kyphotic cervical spine in the protruded-head position

Case report

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In this paper the authors report the case of a patient with ossification of the posterior longitudinal ligament (OPLL) below the axial vertebra (C-2) at the kyphotic cervical spine, with an atlas vertebra (C-1) posterior arch that compressed the spinal cord with the head in a pathognomonic position, similar to a protruded position. This condition appears to be very rare. The morphological findings between the kyphotic cervical spine and OPLL, the upper occipitocervical junction, and the protruded-head position are discussed. A 40-year-old man presented with severe pain radiating to both legs when he yawned, sneezed, or extended his jaw (a protruded-head position). A kyphotic cervical spine with OPLL below C-2 was observed using CT and radiography, yet sagittal T2-weighted MRI failed to identify abnormal findings in a neutral or extension position, except for a slight cervical canal stenosis. However, in a pathognomonic protruded-head position, sagittal T2-weighted MRI showed a C-1 posterior arch that severely compressed the spinal cord at the upper cervical level. Therefore, the authors believe that the severe pain radiating to both legs was caused by a spinal canal stenosis due to a C-1 posterior arch impingement. The C-1 posterior arch was resected, and after the surgery, the patient indicated that the intolerable pain had disappeared. In conclusion, in patients with OPLL and a kyphotic cervical spine, the authors propose that the pathognomonic protruded position is valuable for estimating disrupted compensatory mechanisms at the upper cervical junction.

Abbreviation used in this paper:OPLL = ossification of the posterior longitudinal ligament.

Article Information

Address correspondence to: Mikinobu Takeuchi, M.D., Ph.D., Aichi Medical University Hospital, 1-1 Karimata, Yazako, Nagakute City, Aichi 480-1195, Japan. email: take7106@aichi-med-u.ac.jp.

Please include this information when citing this paper: published online August 2, 2013; DOI: 10.3171/2013.7.SPINE13229.

© AANS, except where prohibited by US copyright law.

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Figures

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    Preoperative lateral radiographs showing the kyphotic alignment under C-2. A: The Cobb angle (C2–7) was −22.5°. B: Dynamic flexion radiograph showing angles of −4.5° (occiput–C1), 34.6° (C1–2), and 32.3° (occiput–C2). C: Dynamic extension radiograph showing angles of −2.3° (occiput–C1), 46.3° (C1–2), and 48.3° (occiput–C2). A negative angle was defined as a kyphotic curve and a positive angle as a lordotic curve. O = occiput.

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    Preoperative axial (left) and sagittal (right) CT scans showing a 6.4 mm thickness (bilateral arrow) and central-type OPLL at C-2, and continuous and segmental OPLL under C-2 (black arrow).

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    Sagittal T2-weighted MR images (lower row) and corresponding head positions (upper row). A and B: Abnormalities of the upper cervical lesion were not detected on T2-weighted MRI in the neutral (A) or extension (B) positions. C: The spinal cord compression at the upper cervical level caused by the C-1 posterior arch was evident in a protruded-head position, which included the patient extending his jaw.

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    Postoperative sagittal T2-weighted MR image in the protruded-head position (A), and postoperative axial CT scan at C-1 (B).

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    Postoperative lateral radiographs showing the kyphotic alignment under C-2. A: The Cobb angle (C2–7) was −16.3°. B: Dynamic flexion radiograph showing angles of −7.7° (occiput–C1), 34.4° (C1–2), and 27.4° (occiput–C2). C: Dynamic extension radiograph showing angles of 0.5° (occiput–C1), 45.6° (C1–2), and 46.2° (occiput–C2).

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