Case 13: Cervical Fusion

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This case begins with a 53-year-old man presenting to his primary care doctor with neck pain. It radiated down into his shoulders and had been worsening chronically over the past several years. He previously had a lumbar fusion that was done about 10 years earlier.

His primary care doctor ordered an MRI of his cervical spine. The results of the MRI are shown below.

After reviewing the results of the MRI, he was referred to a spine clinic for consultation with a surgeon. He went back to the same clinic where he had the previous lumbar fusion.

At the spine clinic, he saw both a neurosurgeon and an orthopedic surgeon with expertise in spine surgery. The orthopedic surgeon’s note is shown below.

The neurosurgeon saw the patient as well and agreed that operative intervention was appropriate.

The patient decided to proceed with the surgery. He signed a consent form and had pre-operative labs drawn, which will be shown on the next page.

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