Case Study: Management of 73-year-old Female

with Cervical Spine Stenosis and Myelopathy

A 73-year-old female with a history of alcoholism, COPD, BPH, aspiration pneumonia, tobacco abuse, and peripheral neuropathy was sent from a rehabilitation Center with complaints of upper extremity weakness, urinary incontinence, decreased sensation to upper and lower extremities.

She was seen in the hospital where she was found to be profoundly weak in her upper extremities and her lower extremities had numbness and tingling.  His imaging studies showed critical stenosis from C3 to C6.  

She was currently on gabapentin, latanoprost, pantoprazole, atorvastatin, tiotropium bromide, and tramadol. The patient was an active smoker. She had no known drug allergies.

CT of the cervical spine demonstrated multilevel posterior disc bulges with bilateral neural foraminal stenosis of the mid to lower cervical spine. Sclerotic hypertrophic degenerative changes were associated with the mid to lower cervical facets.

Preoperative Coronal and Axial CT sections   Preoperative Coronal and Axial CT sections 2

Preoperative Coronal and Axial CT sections.

An MRI of the cervical spine suggested At C3-4, there is a central disc herniation with severe spinal canal stenosis and moderate compression of the cervical spinal cord, with compressive myelopathy. Disc protrusions are identified at C4-5 and C5-6 with moderate narrowing of the thecal sac and mild flattening/compression of the ventral cervical spinal cord. Mild narrowing of the thecal sac at C2-3 and C6-7, with a small central protrusion at C2-3.

Preoperative MRI in sagittal section.

Given the alarming imaging findings and his profound weakness that was fast progressing, we considered this neurosurgical emergency and offered her immediate decompression and stabilization.  She understood all of the risks, benefits, and alternatives to surgery and we had her medically optimized as quickly as possible so that we could address her surgical issues.  She gave informed consent.

The patient was identified in the preoperative holding area by two separate patient identifiers and then brought back to the operating room where she was induced under general anesthesia and intubated without any extension of her neck.  

She was placed prone onto the operating room table with a slight interscapular bump on her head secured in a gel donut.  His arms were tucked to the sides and x-rays were completed to ensure proper visualization of the cervical spine and anatomic positioning. Neuromonitoring was set up.

 At this point, we used a radiopaque marker to localize our incision and centered on the C3-C6 vertebral bodies.  We drew our incision with an indelible marker from the midline of the trachea to the medial border of the sternocleidomastoid muscle at the level of the skin following the natural crease.

Intraoperative fluoroscopic images Intraoperative fluoroscopic images 2

Intraoperative fluoroscopic images.

At this point, we prepped and draped the neck in the usual sterile fashion and completed a call to order.  Perioperative antibiotics were given.

A #15 blade was used to incise the skin down to the level of the subcutaneous fat and thereafter combination of bipolar cautery and Bovie cautery was used to continue the dissection down to the fascia of the platysma muscle.  Subcutaneous dissection was carried out and then the platysma muscle was undermined and cut with the Metzenbaum scissors.  

Bleeding was controlled with bipolar cautery and subplatysmal dissection was carried out in a similar fashion.  The medial border of the sternocleidomastoid muscle was identified and using blunt finger and Kittner dissection, we continued our dissection down to the prevertebral fascia.  

Using handheld Cloward retractors, we exposed the prevertebral fascia identifying the carotid artery laterally both by palpation and visualization of the trachea and esophagus medially.  These were held and protected out of the way and the endotracheal cuff was deflated to adjust for a cuff leak.

We cut the prevertebral fascia with Metzenbaum scissors and inserted a spinal needle to identify our level of operation using fluoroscopy.  We then measured and placed our Trimline self-retaining retractor set and inserted Caspar pins into the C5 and C6 vertebral bodies.

Intraoperative fluoroscopic images 3

Intraoperative fluoroscopic images.

We continued our dissection using Bovie cautery freeing the longus colli muscles from the vertebral bodies and exposing the disc spaces from C3 to C6.  Starting at the C5-C6 level, we incised the anterior annulus of the disc space and started our discectomy to the posterior longitudinal ligament. We applied slight distraction with the Caspar pins and used a combination of curettes, pituitary rongeurs, and Kerrison to complete our discectomy.

We used the 3 mm matchstick drill bit to clear osteophyte from our dissection field both anteriorly and posteriorly and then we undermined the posterior longitudinal ligament with a blunt nerve hook.  We then resected the posterior longitudinal ligament with 1 mm and 2 mm Kerrison punches and removed additional osteophytes with 2 mm and 3 mm Kerrison punches.  

We created wide foraminotomies with a 2 mm Kerrison punch and followed the nerve roots out of their foramen using the blunt nerve hook freeing them from all compressive elements circumferentially.  We then prepared the endplates for arthrodesis using the curettes and the drill and controlled the epidural bleeding with Surgifoam and gentle cotton tamponade.

We then trialed sized our C5-C6 disc space and took x-rays.  Once we are happy with the size of this trial, we collected morselized autograft from the drilling of the bone, and then we brought in our spacer cage measuring 7 mm in height with built-in lordosis.  

We filled this interbody spacer with a combination of demineralized bone matrix, and morselized autograft.  We inserted this into the C5-C6 disc space and then washed it out copiously with bacitracin irrigation.

We then shifted our attention to the C4-C5 disc space and placed a Caspar pin at the C4 vertebral body and repeated the same process for the discectomy and foraminotomies.  At this disc space, there was slightly more significant osteophytic bony overgrowth, which was removed with a drill and Kerrison punches.  

The posterior longitudinal ligament was resected in its entirety and we were again able to fit a 7 mm spacer into the disc space with built-in lordosis.  We filled this with morselized autograft obtained from the drill and Kerrison punches as well as Trinity ELITE and DBX paste.  

We then removed the Caspar pins from the C6 vertebral body and placed it into the C3 vertebral body and frame-shifted our retractors up to the C3-C4 disc space, where we repeated the process for the discectomy and the foraminotomies.

Arthrodesis was once again achieved as with the level below using the drill and curettes as well as morselized autograft and allograft placed into a sustained spacer, which was trial sized and then the final spacer was placed.  At this point, we washed out the wound copiously with bacitracin irrigation and measured our cervical plate.  

We applied lordosis using the handheld lordotic bender to the plate and using fluoroscopy to ensure the appropriate sizing of the plate.  The cervical plate was placed anteriorly and 4.2 x 16 mm screws were then used in the C3, C4, C5, and C6 vertebral bodies.  We obtained fluoroscopy throughout to ensure proper trajectory for the screws.  

Once we were satisfied with the screw placements and the positioning of the intervertebral spacers, we washed out the wound copiously with bacitracin irrigation and created hemostasis using meticulous bipolar cautery.

The wound was checked for inadvertent bleeding and any and all bleeders were controlled with bipolar cautery.  We applied some Surgifoam to the wound and then closed the incision in layers using #3-0 Vicryl sutures in the platysma.  

Deep dermal sutures were then placed using #3-0 Vicryl sutures in the inverted, interrupted fashion followed by #5-0 Monocryl suture in the subcuticular fashion at the level of the skin.  A cervical collar was placed to the patient after the dressing was applied and the patient was extubated in stable condition.

Patient was transferred to rehabilitation center after a brief hospitalization where she had a gradual uneventful recovery.

Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.

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Based on 107 reviews
Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

My name is Dr. Suhirad Khokhar, and am an orthopaedic surgeon. I completed my MBBS (Bachelor of Medicine & Bachelor of Surgery) at Govt. Medical College, Patiala, India.

I specialize in musculoskeletal disorders and their management, and have personally approved of and written this content.

My profile page has all of my educational information, work experience, and all the pages on this site that I've contributed to.