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Post surgical ACDF


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Interesting case in the ER yesterday:

64 y/o female 10 day post-op ACDF presented for increased discharge from the surgical wound that started 3d ago; couldnt get in to see surg because it was sunday. Also c/o mild dyspnea.

Neck pain improving post-op.

ROS: As above plus sleeplessness, HA. No fevers, chills, weakness, dysphagia or cough. No recent illness; no other trauma. All other ROS NEG.

PMH: cervical radiculopathy/ DDD, Fibromyalgia, HTN

PE
Gen: Alert, restless.
HEENT: normocephalic. Noted Ptosis on RT; Pupils: 4-5mm on RT, non-reactive to light; 3mm on LT, brisk response. No consensual response noted OU; defect similar in lit/unlit room. EOMs intact. IOP- 15-17 OU; Vis acuity 20/20 OU.

NECK: Removed from Hard Collar; 6 cm, healing, vertical surgical scar to LT anterior neck. Scant purulence to dsg, minimal soft tissue swelling/erythema, no induration
or fluctuance. No dehiscence. No palpable adenopathy.


NEURO: RT III CN defecit as above; all other CN intact. Grips weak BIL- chronic per pt. A/Ox3. No other focal findings.

-ALL other PE WNL

Labs: cbc, cmp, ua/tox, cta neck ordered out front (ended up having non-con when gfr was <60); final imaging was MRI/MRA brain

 

 

 Any Neuro PA's out there who can school me on this a little?

 

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Yes, my apologies.  Not a very fleshed out case presentation.  Originally just wanted to talk about Horner's syndrome in the cervical fusion patient post-operatively.  Figured there would be a handful of Neuro guys that could explain to me if the approach side means anything, or if contra-lateral Aniscoria could still fall into that DX.

 

My Attending was scratching his head; I couldn't find anything specific enough on UTD or in the literature.

 

 

-J

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1) infection in the surgical bed

2) septic embolic stroke

 

And not a very thorough case presentation from my former student...you forget what I taught you ... =P

 

 

ouch

 

i thought it was pretty good, succinct, to the point....

 

 

 

? position during surgery, palsy? as well as above

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Sorry guys.  ACDF- anterior cervical discectomy and fusion.

 

The patient in question had a Lt sided approach for her fusion; presented as above.  Interesting, because if she had damage to the sympathetic chain on the Lt, you would expect miosis and ptosis on the Lt for the diagnosis of post-operative Horner's.

 

In this pt, she had ptosis on the RIGHT, and I couldn't discriminate definitively whether the pupillary defect was Rt or Lt sided.  (She had a 4-5 mm Rt pupil, non-reactive to light, 3 mm Lt - sluggishly reactive)

 

Either way, she got the MRI/MRA brain and it was negative.  Her original CT neck showed no acute pathology.

 

Referred to Ophtho, back to her Neurosurg, and DC'd home with family.

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Former neurosurgery PA here. What you described are to be expected in some pt post ACDF. Won't had gotten MRI/MRA brain. Instead, a MRI neck would been OK. d/c home on abx w/ recom to f/u surgeon. What describing post ACDF. It's important to state what level e.g. S/p C3/4, and c4/5 ACDF.

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