An (b)(4) patient with neck pain greater than one year was treated with anti-inflammatories and physical therapy.
Patient underwent x-rays on (b)(6) 2003 and was treated with fusion at c6-c7 with an acdf plate and four screws on (b)(6) 2003.
Patient underwent cervical epidural steroid at c7-t1 for shoulder pain and radiating arm pain on (b)(6) 2004 and again on (b)(6) 2004.
A ct scan on an unknown date showed fusion failure and pseudoarthrosis.
Patient underwent a reconstruction procedure with allograft on (b)(6) 2004 without removal of implants.
Patient presented sometime in 2011 with substantial trigger point discomfort right at the paraspinous muscle of the second level of the trapezius and underwent a facet rhizotomy.
Patient then developed neck pain with upper extremity pain.
Emg showed c6 radiculopathy.
Mri showed ddd, hnp at c5-c6 with solid fusion at c6-c7.
Patient was returned to the or on (b)(6) 2012 for removal of the cslp plate at c6-c7.
Patient was treated with anterior c5-c6 biological spacer with allosource cortical cancellous graft, cervical interbody arthrodesis and anterior cervical plate fixation spanning c5-c6.
This report is #2 of 5 for the same event.