Pannus of the dens

Tagged: dens, Neck pain, odontoid, Pannus, paresthesia, wrist problems

Viewing 6 posts - 1 through 6 (of 6 total)

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twice
Participant

April 9, 2016 at 12:14 am

Post count: 3

#21922

I am trying to understand an MRI finding. My doctor has not given it much interest, but doesn’t seem to be able to answer what it is. The report reads: “There is mild soft tissue about the dens likely reflecting a pseudopannus formation” I had virtually no luck finding the term pseudopannus but did find a few things about a pannus around the dens or odontoid pannus. Most search results seem to be about this structure in relation to rheumatoid arthritis, which I have not been diagnosed with.

My questions are:
– Is the pseudopannus formation likely the same as a pannus around the dens?
– Should I be pushing my doctor to take a closer look or possibly seek out another doctor or specialty?
– Can this be the cause of various cervical symptoms- they were looking for the cause of my wrist pain and numbness, but I also get neck and shoulder pain, a “crick” in the neck for lack of a better word where very thing just tightens up. Occipital headaches usually occur with this neck pain.

Donald Corenman, MD, DC
Moderator

April 9, 2016 at 4:18 am

Post count: 8660

#21923

This pannus is called a “Pseudopannus” as it looks like a pannus but does not have the origin that these pannuses typically have (rheumatoid arthritis). A pannus is a mass of synovial and inflammatory tissue around a joint. If the C1-2 level is stable, then there is no cause for alarm. Stability means the dens is intact (not fractured or eroded) and the transverse ligament is intact-the atlantodens interval (the space between the dens of C2 and the front of the ring of C1) is less than 1-2 mm.

This pseudopannus will not cause arm symptoms. The origin could be gout or pseudo-gout (calcium pyrophosphate disease). You might get some tightness of rotation of your head. There is an unlikely possibility of headaches but this would be distinctly unusual.

You probably have some other disorders of your neck that are contributing to your symptoms.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.

Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

twice
Participant

May 21, 2016 at 8:12 pm

Post count: 3

#22218

Thank you so much for your explanation and sorry for the belated response. The explanation of what stability means in this context is really helpful. I assumed instability meant unstable, as in “wobbly” or hypermobility, and couldn’t figure out how one could know that from looking at just the MRI. Now I know what it means and it makes sooo much more sense.

I do have a tiny protrusion at c6-7 but it is just that, tiny, so I don’t know if that’s even possible to be responsible for the neck symptoms. But it looks to me that from the 2012 MRI to now it’s changed- there seems to be signal intensity in the protrusion. However, the 2012 MRI images are a bit blurry, so it could that more image clarity makes it more visible as opposed to a change.

One thing I’ve been wondering about is that I have two cervical MRI’s- one from 2012, and one from this year. The one from this year lists no findings. The one from 2012 has the finding of the pannus and had the tiny protrusion. I asked the ordering physician if that meant the protrusion and the pseudopannus from the previous report healed and went away. She gave me a kind of non-answer. Troubled by that, I spend some time figuring out how to view my MRI’s and finding those two features. Both still exist on the current MRI even though they are not in the 2016 report. I’m fairly confident what I’m seeing is what I’m seeing, I spent a lot of time staring at MRI films online to get a sense of what these things look like on an MRI. I’m not sure what to do or if this matters. I have not seen a neurosurgeon, but plan to due to a thoracic protrusion that is causing me lots of pain. I don’t want something missed because the most recent report doesn’t accurately reflect what’s there. What is the protocol for something like this? Does it matter?

Lastly, looking at the pseudopannus on the MRI- it does appear to press into the thecal sac quite a bit, though does not appear to impinge the cord. It’s very close though. If I’ve got the scale right (and that might be a big if), it appears there is somewhere between 1 and 2mm of space between it and the cord. Can this cause problems, now or if the pseudopannus should get bigger? This is part of the reason I’m wondering if I should be making sure my that the newest MRI report is accurate. I feel kind of lost; a friend who is a medical professional from another state commented recently how below par the care I’ve received here is. But I’m not sure what I can do about that but it does leave me with some doubt about leaving this discrepancy as is, unless it’s truly inconsequential.

Donald Corenman, MD, DC
Moderator

May 21, 2016 at 9:47 pm

Post count: 8660

#22220

The pannus being “close” to the cord does not really matter if there is plenty of space behind the cord. There is an acknowledged rule called “Steels rule of thirds”. At the level of C1, there should be 1/3 of the space for the odontoid, 1/3 of space for the cord and 1/3 of space for CSF. You probably are OK at that level.

Also, with different MRI machines and different radiologists, you can’t avoid different readings. What you need is a kind, verbose, educational spine surgeon or neurosurgeon who can go over your MRIs and fulfill the answers to your questions.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.

Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

twice
Participant

May 21, 2016 at 10:53 pm

Post count: 3

#22221

“What you need is a kind, verbose, educational spine surgeon or neurosurgeon who can go over your MRIs and fulfill the answers to your questions.”

Any suggestions on how to find one of those? I’m in Milwaukee, WI and travel isn’t an option unfortunately, or I know where I’d be going. I’ve been lurching and reading your forum archives for several months. Primary concern is a symptomatic thoracic herniation at t7-8. I’ve got a few recommendations from doctors I see, but they’re more of the “they’re in the same medical group as me, so here is who we recommend.” My reluctance to see one of those is that so far the medical professionals I’ve seen don’t have much experience with thoracic disc problems. The most common response is that it’s unusual. I also want someone to look at the cervical MRI, but that is of secondary concern. Even suggestions on how to vet a good spine surgeon would be helpful.

Donald Corenman, MD, DC
Moderator

May 22, 2016 at 8:26 am

Post count: 8660

#22224

Finding a good spine surgeon is difficult. You can go through the section https://neckandback.com/treatments/best-questions-to-ask-when-interviewing-a-spine-surgeon/ to gain some knowledge about questions to ask but some surgeons might be put off when you ask about their qualifications.

Thoracic disc herniations are somewhat uncommon. In my practice, they occur less than 1% of all patients. The history and physical examination have to match with the pathology. You then need to get a selective nerve root block to make sure the HNP is the pain generator. This will identify the pain source and may even treat it. If surgery is necessary, there are many different approaches. I prefer the posterolateral approach but some surgeons are skilled at the VATS procedure (video assisted thoracic endoscopy).

Please keep us informed of your progress.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.

Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.
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Donald Corenman, MD, DC

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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