Transient neurological deterioration following Anterior Cervical Discectomy and Fusion (ACDF)
Case report and literature review
To validate, the current understanding on aetio-pathogenesis and management of neurological deterioration following anterior cervical discectomy and fusion (ACDF) procedure.
Single-level ACDF is a relatively straight-forward procedure commonly indicated for symptomatic cervical myelo-radiculopathy. Transient neurological deterioration (TND) is observed rarely post-operatively, which is poorly understood in literature.
A 44 year old male presented with a 5 month history of progressive neck pain, left arm pain & paraesthesia along with weakness affecting left upper and lower limb. MRI revealed C5/C6 disc prolapse and an ACDF procedure was performed. Immediately postoperatively, the patient developed left-sided hypothesia and hemiparesis. Emergent postoperative MRI work-up revealed T2 hyperintense MRI myelopathy changes without haematoma, pseudo-meningocoele or implant displacement. His TND returned to pre-operative levels in 3/4 hours. He was discharged day 2 post-operatively. At 6 months review, the patient achieved excellent improvement in clinico-symptomatology.
Existing evidence is sparse regarding aetio-pathogenesis of post-ACDF TND in the absence of intraoperative insult or precipitating factors identified on postoperative imaging. We ascribe this phenomenon to microvascular transient ischemia with reperfusion.
Our recommendation to manage this: regular 15 min neuro-charting,emergent MRI imaging, short course of dexamethasone. In case of rapid deterioration in neurology, return to theatre without imaging may be justified.
Transient neurological deterioration is a rare albeit dreaded complication that occurs immediately following ACDF procedure. For patients as well as medical staff coming across such a phenomenon, we propose here the aetiopathogenesis and management.