A case of cervical metastases in a patient with preexisting cervical disc replacement and fusion after 2-year symptom-free interval: when do we need interdisciplinary diagnostics?

Recurrent cervical symptoms frequently occur after cervical disc replacement and fusion. To date, no algorithm for the diagnostic assessment of these symptoms has been established. We present a case report and review of the literature to illustrate the need for interdisciplinary diagnostics in recurrent cervicobrachialgia without pathological cervical imaging. The hospital chart, medical history, physical examination, and imaging of a single patient were reviewed. A 53-year-old man with preexisting cervical disc replacement and fusion presented with a new episode of cervicobrachialgia after a 2-year symptom-free interval. Cervical magnetic resonance imaging (MRI) showed no pathological findings. Six months later the patient reported increasing symptoms including numbness and weakness of the right arm. Repeated cervical MRI and thoracic computed tomography revealed cervical metastases with intraspinal tumor growth and an underlying extensive small cell bronchial carcinoma. In recurrent cervicobrachialgia, without pathological cervical imaging, interdisciplinary diagnostics are needed. Basic diagnostic tests may assist to exclude severe non-vertebrogenic pathologies.

Introduction

Recent years have seen growing numbers of cervical disc replacements and fusions due to improved surgical techniques.1,2,3 Diagnostics and differential diagnostics have been highly standardized;4 however, recurrent cervical symptoms frequently occur.5 Possible vertebrogenic causes lie within the treated or adjacent segments (Table 1).6. Primarily, local diagnostics of these causes are required (Table 2); yet, no algorithm for the diagnostic assessment of recurrent cervical symptoms has been established to date.7 This bears the risk that non-vertebrogenic causes of cervical symptoms are diagnosed at a late stage.

Table 1

Causes of vertebrogenic symptoms after cervical disc replacement/fusion.

Adjacent segment degeneration

New or persisting central or foraminal stenosis

Pseudarthrosis

Vertebral fracture

Cage/prosthesis migration

Prosthesis loosening

Facet joint degeneration

Wear-induced granuloma

Misalignment

Nonphysiological load and movement patterns

Table 2

Local diagnostics for recurrent or persistent vertebrogenic symptoms after cervical disc replacement/fusion.

Standard and oblique view x-ray

Functional x-ray

Computed tomography (CT)

Myelography

CT-myelography

Magnetic resonance imaging (MRI)

Contrast MRI

Dynamic examination with image intensifier

Scintigraphy

Positron-emission tomography-CT

Electroneurography/electromyography

Somatosensory evoked potential test

Magnetic evoked potential test

Psychological exploration

Facet joint and nerve root blocks

Discography

Report of a Case

A 53-year-old nonsmoking man presented to our outpatient clinic with a new episode of cervicobrachialgia after a 2-year symptom-free interval. Two years ago, because of bilateral foraminal stenosis at C5/6 and C6/7 with increasing cervicobrachialgia, decompression and fusion at the severest level C5/6 (Pina Titan Cage 8 mm 14 × 16 mm) and disc replacement at C6/7 (Prodisc-C XL 8 mm) had been performed due to different degenerative changes. In the preoperative routine check-up the patient had presented without a history of a malignant comorbidity. In the further course he had been symptom free. Routine cervical x-ray had shown a stable fusion and a beginning kyphosis of the disc prosthesis (Fig. 1). Two years after surgery the patient reported recurrent cervicobrachialgia; however, cervical magnetic resonance imaging (MRI) including STIR sequences showed no pathological findings except for incipient foraminal stenosis at levels C3/4 and C4/5 due to uncovertebral arthrosis (Fig. 2). Therefore, no further imaging or invasive investigations such as computed tomography (CT)-myelography were indicated.

Fig. 1

(a) Postoperative cervical x-ray, lateral view. (b) Postoperative cervical x-ray, anteroposterior view.

Fig. 2

A 2-year postoperative cervical MRI, T2-weighted sagittal view.

During the next 6 months his symptoms got worse with increasing numbness and weakness of the right arm. Repeated cervical MRI revealed bone metastases of the fourth and fifth vertebrae with intraspinal tumor growth (Fig. 3). Thoracic x-ray and CT demonstrated an extensive small cell bronchial carcinoma (Figs. 4,5). Beginning paraparesis required immediate treatment comprising debulking, radiotherapy as well as etoposide and cisplatin chemotherapy. Subsequent to deterioration of his general state of health, the patient died 2 weeks after the cancer diagnosis of cardiopulmonary decompensation.

Fig. 3

(a) A 2.5-year postoperative cervical MRI, T2-weighted sagittal view. (b) A 2.5-year postoperative cervical MRI, T1-weighted axial view.

Fig. 4

A 2.5-year postoperative thoracic x-ray, anteroposterior view.

Fig. 5

A 2.5-year postoperative thoracic CT, axial view.

Discussion

Good-to-excellent clinical results with a low complication rate are reported for ventral cervical fusion and disc replacement.8,9,10 This applies likewise to disc replacement in combination with fusion.11,12 Yet, postoperative cervicobrachialgia is not uncommon.5,13,14 Especially after a symptom-free interval of 2 years recurrent cervical symptoms are often believed to result from vertebrogenic causes. Metal artifacts complicate the evaluation of MRI and CT scans.15,16,17 The absence of neurological deficits demands a nonsurgical treatment leading to a successful outcome in most patients.6 However, recurrent cervicobrachialgia without pathological cervical imaging requires interdisciplinary diagnostics.

To our knowledge, there is only one report of a similar case in the literature. Pillai et al 18 presented the case of a patient developing metastases at the site of the arthroplasty 1 year after fusion at C3/4 to caution spine surgeons about the possibility that metastases might occur at the site of a cervical fusion and that a metastatic tumor should be accounted for in the differential diagnosis of recurrent cervicobrachialgia.

Potential nonvertebrogenic causes of cervicobrachialgia are given in Table 3. Basic diagnostic tests, such as thoracic x-ray, erythrocyte sedimentation rate, C-reactive protein, and electrocardiogram may assist to exclude severe nonvertebrogenic pathologies. These tests are highly recommended in cases without pathological cervical imaging.

Table 3

Potential nonvertebrogenic causes of cervicobrachialgia.

Migraine

Herpes zoster

Toothache

Torticolli spasticus

Oral and maxillofacial tumors

Pancoast tumor

Breast cancer

Spastic esophagus

Hiatus hernia

Pneumothorax

Pleuritis

Pulmonary embolism

Myocarditis

Angina pectoris/myocardial infarction

Aortic aneurysm

Peripheral artery disease with ischemia

Sudeck atrophy

Carpal/radial/cubital tunnel, pronator teres, scalenus, thoracic outlet syndrome

Epicondylitis humeri

Serogenetic polyneuritis

Basilar impression and similar skeletal deformities

Neuralgic shoulder amyotrophy

Shoulder impingement syndrome/omarthritis/omarthrosis

Polymyalgia rheumatica

Neurotic disorders

Conclusion

This case illustrates the need for interdisciplinary diagnostics in recurrent cervicobrachialgia without pathological cervical imaging. Basic diagnostic tests may assist to exclude severe nonvertebrogenic pathologies.