What is the best course of action for a 60-year-old female with a history of cervical spine surgery and fusion, asthma, obesity, and hypertension, presenting with left posterior neck pain, left-sided headache, and altered sensation of the left side of the tongue?

Urgent Neurosurgical Referral for Cervical Myelopathy Evaluation

This patient requires urgent neurosurgical consultation for probable cervical myelopathy given her constellation of cranial nerve XII palsy (tongue deviation/heaviness), cervicogenic headache, posterior neck pain, and severe multilevel foraminal stenosis at C7-T1 and T1-T2 on MRI, particularly in the context of prior extensive cervical fusion that may be causing adjacent segment disease.

Critical Clinical Findings Requiring Immediate Action

Cranial Nerve XII Involvement

• Left tongue deviation, heaviness, and altered sensation represent lower cranial nerve dysfunction that is not explained by cervical radiculopathy alone 1
• This suggests either cervicomedullary compression at the craniocervical junction or a separate brainstem/skull base process 2
• The combination of CN XII palsy with cervicogenic headache and neck pain warrants urgent evaluation for compression at the foramen magnum or upper cervical spine 2

Myelopathic Red Flags Present

• History of falls and stumbling suggests gait disturbance, a cardinal sign of cervical myelopathy 1
• Bilateral symptoms (right hand numbness from prior surgery, new left-sided symptoms) raise concern for spinal cord involvement 1
• Facial twitching may represent upper motor neuron signs 1
• Initial NIH stroke scale of 6 indicates significant neurological deficit 1

Imaging Findings Demanding Action

• Moderate to severe canal stenosis at C7-T1 with severe bilateral foraminal stenosis at T1-T2 represents critical compression below the prior fusion construct 2
• Ossified posterior longitudinal ligament (OPLL) from C2-C7 is a progressive condition that causes spinal cord compression 2
• Prior fusion from C2-C7 places this patient at high risk for adjacent segment disease at C7-T1 and below 2

Immediate Diagnostic Steps

Obtain Thoracic Spine MRI Without Contrast Immediately

• The cervical MRI specifically recommends "dedicated MR thoracic spine as indicated" given severe stenosis at T1-T2 2
• This is critical to evaluate the full extent of cord compression and any thoracic myelopathy 2
• MRI without contrast is the preferred modality for evaluating spinal cord compression and signal changes 2, 1

Comprehensive Neurological Examination

• Document specific myelopathic signs: Hoffmann's sign, Babinski sign, hyperreflexia, clonus, and inverted radial reflex 1
• Assess gait formally (tandem, heel-to-toe walking) to quantify the reported falls/stumbling 1
• Evaluate for bowel/bladder dysfunction and perineal sensation 1
• Perform detailed motor examination of all extremities to detect upper motor neuron weakness 1

Evaluate for Skull Base/Posterior Fossa Pathology

• The negative CTA and MRI brain do not fully exclude pathology at the craniocervical junction or foramen magnum 2
• Consider dedicated MRI of the craniocervical junction with attention to the foramen magnum and lower cranial nerves 2
• CN XII palsy with cervicogenic headache may indicate compression at the hypoglossal canal or jugular foramen 2

Surgical Consultation Urgency

Indications for Urgent Neurosurgical Referral

• Symptomatic cervical stenosis with myelopathic signs requires timely surgical decompression to prevent permanent neurological injury 2
• Anterior cervical decompression and fusion (ACDF) at C7-T1 may be indicated for rapid relief of radicular and myelopathic symptoms (within 3-4 months) 2
• Adjacent segment disease below prior fusion often requires extension of the fusion construct 2
• OPLL may require specialized surgical approach (anterior corpectomy vs posterior laminectomy with fusion) depending on extent and location 2

Timing Considerations

• Do not delay surgical consultation while pursuing conservative management given myelopathic signs 2, 1
• Progressive motor weakness, gait disturbance, and cranial nerve involvement indicate active neurological deterioration 1
• Untreated spinal cord compression leads to irreversible injury and permanent disability 2

Critical Pitfalls to Avoid

Do Not Attribute All Symptoms to Radiculopathy

• Cervical radiculopathy does not cause CN XII palsy, facial twitching, or gait disturbance 1
• The outpatient EMG recommendation from neurology is insufficient for this clinical scenario 1
• EMG evaluates peripheral nerve and nerve root function but cannot assess spinal cord or brainstem pathology 3

Do Not Pursue Conservative Management Alone

• While 75-90% of cervical radiculopathy resolves with conservative treatment within 6-8 weeks, this patient has myelopathic signs that require surgical evaluation 1
• Conservative management is contraindicated when progressive neurological deficits are present 1
• The presence of severe stenosis on MRI with corresponding clinical myelopathy is an indication for surgical decompression 2, 1

Do Not Overlook Adjacent Segment Disease

• Patients with prior cervical fusion are at high risk for accelerated degeneration at adjacent levels 2
• The C7-T1 and T1-T2 stenosis likely represents adjacent segment disease from the C2-C7 fusion 2
• This often requires extension of the fusion construct rather than isolated decompression 2

Specific Management Algorithm

1. Today: Order MRI thoracic spine without contrast and arrange urgent neurosurgical consultation (within 24-48 hours) 2, 1

2. Within 48 hours: Complete comprehensive myelopathy examination and consider MRI craniocervical junction if CN XII palsy etiology remains unclear 2, 1

3. Neurosurgical evaluation: Determine need for surgical decompression at C7-T1/T1-T2 with possible fusion extension 2

4. If surgery declined or delayed: Close neurological monitoring every 1-2 weeks for progression, with immediate surgical referral if worsening 1

5. Postoperative: Early mobilization and rehabilitation to address gait disturbance and prevent complications 2