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TOPIC: 4-level ACDF

4-level ACDF 2 years, 5 months ago #2188

Dr. Corenman,

Thank you very much for setting up this forum.

I am a 41 year-old male and have been to several surgeons and treatment recommendations have been from one end of the spectrum to the other so I'm very confused on what needs to be done to fix my problems.

Symptoms:
My symptoms started just over 5 months ago with pain in my right shoulder blade. As the weeks progressed, I developed excruciating pain down my right arm (both on the inside and outside of the arm), numbness and slight loss of function in my right arm. Currenly, the pain in my right arm is much better, but I do have occasional pain in the upper right arm depending on the day. I also notice slight weakness compared to my non-dominant left hand. I have slight pain in my neck, but quite a bit of numbness in the neck (mostly on the right side). I also still have pain in my right shoulder and shoulder blade which varies in severity.

MRI Results:
Findings:
No bone marrow contusion or fracture is seen. Moderate muliple disc desication is seen with some protrusions. There is straightening of the typical lordosis of the cervical spine. Facet joints align normally. Included imaging of the posterior fossa, cervical spinal cord, and proximal thoracic spinal cord all appear unremarkable.

C2-C3: Minimal diffuse disc bulge with a mild focal central protrusion. Mild facet arthropathy. No significant center canal or neural foraminal narrowing.

C4-C5: Moderate right paracentral focal protrusion with mild diffuse disc bulge. Mild left greater than right facet arthropathy is seen. Findings result in moderate left and mild right neural foraminal narrowing. There is mild/moderate central canal narrowing with some deformity of the anterior cervical spinal cord to the focal protrusion.

C5-C6: Asymmetric right mild diffuse disc bulge with mild bilateral facet arthropathy. No significant center canal or neural foraminal narrowing.

C6-C7: Mild to moderate diffuse disc bulge with moderate left lateral focal protrusion. Mild bilateral facet arthropathy. Severe left and moderate to severe right neural foraminal narrowing is seen. There is mild central canal narrowing with effacement of the anterior CSF space.

C7-T1: Unremarkable

Treatment:
I've tried physical therapy with no relief. I've also had three steroid injections. Two in the C6-C7 nerve and one facet block in the C6-C7.

Measurements of spinal canal:
I've been told I have Congenital Cervical Stenosis.
C2/3: 11mm
C3/4: 9mm
C4/5: 6mm
C5/6: 9mm
C6/7: 7mm
C7T1: 9mm

One surgeon (that did the measurements above) recommends a C4-T1 ACDF. Others have definitely been concerned about the C4/5 and C6/7 discs as they say the dangers in the cord compression and my pain/numbness symptoms won't get better and there is risk of paralysis and they believe there is already damage from the cord compression. Some have recommended only an ACDF of C4/5 and C6/7 while others have said to wait and see if the symptoms improve.

I'm wondering if you would be able to give your opinion based on the information I've provided. I can also send you the MRI if that would be helpful. The one thing that doesn't really make sense is the MRI report lists the C7/T1 as unremarkable, however I can definitely see some protrusion and compression.

Thank you very much.

Rick
Last Edit: 2 years, 5 months ago by whatthe2.

Re: 4-level ACDF 2 years, 5 months ago #2190

Pain in the right shoulder and arm associated with weakness is typically a nerve root compression syndrome. That is normally from foraminal stenosis. The physical examination is normally very revealing to identify the involved root or roots. Weakness of the deltoid muscle is C5; weakness of the biceps is typically C6 and weakness of the triceps is involvement of the C7 root.

Sensory involvement is along specific dermatomes (discreet patches of skin) tested by a pinwheel. FInally, neck extension (bending backwards) can cause increased pain from further narrowing of the foramen.

Your MRI notes at C4-5 (C5 nerve) "moderate left and mild right neural foraminal narrowing". If the radiologist has read this accurately, this level has only mild nerve compression on the right so that level is less likely to cause symptoms.

At C5-6 (C6 nerve), the radiologist notes "no significant center canal or neural foraminal narrowing". If he is correct, that level can be ruled out.

At C6-7 (C7 nerve root), "severe left and moderate to severe right neural foraminal narrowing is seen. There is mild central canal narrowing with effacement of the anterior CSF space". That sounds like the level of major involvement both with nerve compression and central canal narrowing.

The surgeon you consulted with noted relatively severe narrowing of the spinal canal but that was not noted by the radiologist. The radiologist did note mild to moderate narrowing of the canal at C4-5 but mild at C6-7.

Break the problem down into what is currently causing symptoms and what could cause a potential injury in the future. More likely than not, C6-7 is causing your current symptoms of right arm and shoulder pain. You have had two epidurals at C6-7. Assuming they were specific (the injectionist did not flood the canal and drove the medication up to C4-5), how did you do for the first three hours after the injection (see pain diary on the website)? If you had good but temporary relief, the C6-7 level is causing your shoulder and arm pain. This will have to be addressed with an ACDF or ADR (see website).

The next question is the C4-5 level. If the narrowing is severe (and there appears to be a disagreement between surgeon and radiologist), possibly the level might need to be addressed surgically. If you do not participate in situations that put your neck at risk, (mountain biking, horseback riding, motorcycle riding, etc..) you might be able to live with that level with some mild inherent risk.

If you do put your neck at risk or do not want to live with the risk, two surgeries can be contemplated at C4-5, an ACDF (fusion) or a laminectomy. Based upon the limited information here, you do not need a 4 level ACDF.

Dr. Corenman
Dr. Corenman

This answer is for educational purposes only and is not a substitute for a diagnosis from a qualified professional. Do not try to diagnose or treat yourself based solely upon reading this material.

back pain forum • lower back pain forum • spine surgery forum • neck pain forum

Re: 4-level ACDF 2 years, 5 months ago #2192

Dr. Corenman,

Thank you very much for your reply (especially on a Holiday).

I’m in Denver and will actually be in Vail in about a week and half so I will be calling your office tomorrow to schedule a visit. If that is too soon, no matter, I will make the trip to Vail when you are available.

You mentioned that neck extension (bending backwards) can cause increased pain from further narrowing of the foramen. Bending my head backwards (and to the right) causes me the most amount of pain and discomfort.

I think you are spot-on with your assessment that C6-7 is causing the problems at this point. The first Epidural was directly into C6-7 and I didn’t have much relief to speak of. For the second Epidural, they went in under the T1 and then up the right side to the C7 and I had immediate relief and significant relief for a couple weeks. The third (Facet block in the C6-7) didn’t provide any relief. Nothing has been done to the C4-5.

Regarding the C4-5 narrowing, I’m with you that there is a discrepancy between the Radiologist and the Surgeon I saw most recently. That is what is causing me the most concern at this point. I do not participate in activities to put myself at risk, but I’m not certain if I am currently doing damage to the spinal cord at this point or not. I understand that if I get in a car accident or fall, etc. I could have problems, but am I doing damage as we speak? The last surgeon left me with the feeling that I am doing damage right now and it will continue to degrade until it’s fixed. (This may require further evaluation on your part, so I understand if you can’t answer at this point).

Regarding ADR, none of the surgeons mentioned this as an option to me, but I did find out about this as I did some research. I mentioned this to the last surgeon I saw, but since he was recommending a 4-level, an ADR was out of the question. If this is still a possibility, I’m all for looking into it.

I definitely would like to explore tackling the two issues that seem to be the most critical at this point (the C4-5 and the C6-7). I can live with the pain and discomfort (for now), and look forward to meeting you in person for a more thorough examination, but at this point do you think there is reason to be concerned that I’m doing permanent damage to my spinal cord in C4-5 because of the compression? I'd rather not rush into making a decision if I still have some time to explore the best solution.

Thanks again.

Rick

Re: 4-level ACDF 2 years, 5 months ago #2194

According to the radiologist, the cord appears normal. Injury typically appears as a "white" signal in the normal appearance of the cord. The physical examination also would note changes called "long tract signs" including hyperreflexia, Hoffman's sign, clonus and sensory changes.

It is hard to know over the internet if you are doing damage to the cord but if the examination did not reveal those signs and the radiologist did not note signal change in the cord, the chances of injury at this point are not high.

The wait time for new patients is somewhat longer than 2 weeks but call the office and tell them we have conversed over the Forum and they will get you in.

Dr. Corenman
Dr. Corenman

This answer is for educational purposes only and is not a substitute for a diagnosis from a qualified professional. Do not try to diagnose or treat yourself based solely upon reading this material.

back pain forum • lower back pain forum • spine surgery forum • neck pain forum

Re: 4-level ACDF 2 years, 5 months ago #2196

Understood, it's definitely hard to say anything for certain corresponding over the Internet, but the information you have provided, along with what I have read on your website definitely makes me feel better about waiting to see you.

I've left a message with your assistance to schedule a visit. I look forward to seeing you soon.

Thanks again.

Rick

Re: 4-level ACDF 2 years, 5 months ago #2197

Hi Dr. Corenman,

I've got an appointment to see you on Aug. 23. I'm wondering if I can ask one last favor of you prior to my visit? My wife is somewhat freaking out at waiting that long since the last surgeon we saw said I should be in surgery pretty much immediately because in his opinion, "you are doing damage to your spinal cord right now". I've been in severe pain since January, so a bit longer doesn't bother me, but if I can ease my wifes concerns and assure her that I'm ok to wait to see you, we sure would appreciate it.

I've copied images from my MRI and posted them on Google Docs (no download necessary, so risk of virus). I'm hoping that the pictures will further your opinion that chances of injury at this point are not high. Again, I know it's not the full exam needed to say for sure, but maybe they can be useful.


Thanks again.

Rick
Last Edit: 2 years, 5 months ago by Dr. Corenman.
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