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Abstract: The patient in this case developed pain in the neck, back of shoulder, and upper limbs 3 years ago, but did not pay attention to it at that time, and only took medication to relieve the pain on her own. Later, because of the poor effect of conservative treatment, she came to our hospital, and after physical examination and imaging examination, the patient was diagnosed with cervical disc herniation and underwent surgery, and recovered well after surgery, and the patient’s discomfort disappeared.
Basic information】Female, 58 years old
Disease Type】Protruding disc (cervical disc herniation)
Hospital】The First Hospital of China Medical University
Consultation time】July 2020
Treatment plan】Surgical treatment (anterior cervical decompression graft fusion internal fixation) + medication (injectable propacetamol hydrochloride, injectable methylprednisolone sodium succinate)
Treatment period】2 weeks of inpatient treatment, 10 weeks of home observation, 3 months of outpatient follow-up
Treatment effect】Local compression was relieved and neck movement was normal
I. Initial consultation
The patient, female, 58 years old, complained of dull pain in the neck, scapular region and left upper limb with no obvious cause 3 years ago, which was relieved by bed rest, and the pain was relieved after self-medication (specific details not available). On examination, it was suggested that there was pressure pain in the neck, pressure pain in the left scapular region, pressure pain in the left shoulder, pressure pain in the left elbow, and mild limitation of movement. The cervical spine X-ray and the cervical spine CT clearly showed cervical disc herniation, and after communicating with the patient and her family, she was hospitalized with cervical disc herniation and underwent follow-up examination and treatment.
II. Treatment process
After admission, the patient was further examined by MRI of the cervical spine, and the examination results indicated herniated discs at C3/4, C4/5, C5/6, C6/7 and spinal stenosis at C3/4 and C4/5 levels; degenerative changes in the cervical spine and different degrees of compression of the dural sac. The patient was treated with intravenous propacetamol hydrochloride and sodium methylprednisolone succinate for injection to relieve pain and prevent lung infection. At the same time, povidone-iodine cotton balls were used to scrub the urethral orifice 2-3 times daily to prevent urinary tract infection, and the patient’s vital signs were closely monitored and local blood flow was observed.
III. Treatment effect
The patient’s surgical treatment hand relieved the compression of the protruding cervical disc, and at the same time increased the stability of the cervical spine through intervertebral bone graft and plate internal fixation, thus improving the patient’s discomfort symptoms and achieving the purpose of cure. And the postoperative compliance was good, and no serious postoperative complications occurred. After 2 weeks of hospitalization, the results of the reexamination were not abnormal, and the patient agreed to be discharged. Ten weeks after discharge, the review X-ray showed that the bone graft line was blurred and there was continuous bone scab formation, which indicated that the patient was healing well.
IV. Precautions
The patient could move his limbs appropriately in bed after surgery, such as stretching of limbs, fist clenching and fist loosening, etc., but during the exercise process one should pay attention to protect the cervical spine. At the same time, before the patient was discharged from the hospital, I instructed the patient’s family that the patient could wear a neck brace and take a walk indoors accompanied by the family, but each walk should not be too long, and the activity time could be gradually increased, and the intake of dairy products and soy products could be increased to promote the patient’s recovery. If there is any discomfort in the neck, the patient should go back to the hospital promptly.
V. Personal insight
The patient first experienced neck discomfort three years ago, but it did not attract his attention at that time, and he only took painkillers on his own to improve his discomfort and did not adjust his living habits, which led to the later aggravation of cervical disc herniation and the appearance of compression symptoms, delaying the best time for treatment, but it is good that the patient later sought the help of a professional doctor, but due to the long duration of the disease and the fact that he has not been The patient sought help from a professional doctor, but because of the long duration of the disease and the lack of systematic treatment, the patient was treated with surgery, which was suitable for the patient.