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I am receiving differing opinions on the cause of my symptoms and I’m desperate for a diagnosis.
My symptoms are:
Right Side: sciatica lower back into foot; backache, buttock pain, hypersensitivity of the skin down my thigh, sharp outside knee pain (that has persisted and worsened despite total knee replacement in 2015), burning on the sides/back of my calf, numbness in foot. Unexpectedly rolled my (right) ankle in 2015 breaking both bones but I felt very little pain. Left Side: Painless left leg weakness; this has worsened over the past four years, I often drag my foot/toes. While lying in bed, I sometimes have clonus of my left foot. Intermittent pins and needles in left arm with clumsy fingers. I have lost the ability to heel walk on my left foot. I have difficulty walking in a straight line and trouble especially walking on uneven ground. Neck: I have no neck pain.Neurological exam (7/25/17): “Deep tendon reflexes were normal on right. She had slightly brisk reflexes on the left with a positive Hoffman’s sign on the left and 2-3 beat clonus on the left, but not the right. Her toes were equivocal to plantar stimulation.” “…hypesthesia to pinprick throughout most of her right leg in a non-dermatomal pattern.”
Cervical Spine MRI on 9/26/17:
“IMPRESSION: No significant interval change in the appearance of the cervical vertebral bodies or the cord with persistent severe canal stenosis cord compression with focal cord atrophy and T2 signal abnormality at the C5-C6 level.”Lumbar Spine Computed Tomography (CT) with Contrast 7/12/17:
“L4-L5: There is grade 1 anterolisthesis of L4 and L5 with disc space narrowing and vacuum phenomenon. There is greater right foraminal and lateral disc extrusion with cephalad migration, essentially occluding the right L4-L5 foramen, causing severe foraminal stenosis. There is no left foraminal narrowing. There is mild thecal sac narrowing. There is severe facet arthropathy and right greater than left ligamentous thickening.”“L5-S1: It is presumed this level is fairly physiologically sacralized as there is no disc space narrowing, protrusion, canal or foraminal narrowing. There is no significant facet arthropathy.”
“There is moderate bilateral L2-L3 foraminal narrowing.”
The controversy seems to center on whether the abnormal signal in my cervical spinal cord at C5 is causing my symptoms or is it the spondylolisthesis of L4-L5? My surgeon does not agree that I have “severe canal stenosis cord compression” because he sees spinal fluid all the way around the cord and the stenosis is not exactly at the same level as the cervical cord signal abnormality. He does not feel L4-L5 surgery would be of benefit because since the L4 nerve root is compressed (he says the L5 nerve root is not compressed) I should have pain in the front of my calf, and I don’t (I have pain on the sides and back of my calf). I saw a neurologist and was told he does not know what the “white spot” in my cervical cord is – it is not MS (I have had all tests to diagnose MS), it is not a tumor; he told me nothing could be done about it. I have had injections in the right L4 and right L5 nerve roots and they did not relieve my symptoms.
Hope you can help; my husband and I are not enjoying the retirement we had envisioned.
With the report of “persistent severe canal stenosis cord compression with focal cord atrophy and T2 signal abnormality at the C5-C6 level” and the presence of myelopathy signs (“slightly brisk reflexes on the left with a positive Hoffman’s sign on the left and 2-3 beat clonus on the left”) and symptoms (“I sometimes have clonus of my left foot. Intermittent pins and needles in left arm with clumsy fingers. I have difficulty walking in a straight line and trouble especially walking on uneven ground”, this seems to be clear cut cord compression with myelopathy. I am unclear why your neurosurgeon does not add up all these factors and consider fixing the C5-6 level. See https://neckandback.com/conditions/cervical-central-stenosis-and-myelopathy/
This goes the same for the L4-5 level (“There is grade 1 anterolisthesis of L4 and L5 with disc space narrowing and vacuum phenomenon. There is greater right foraminal and lateral disc extrusion with cephalad migration, essentially occluding the right L4-L5 foramen, causing severe foraminal stenosis”). This report goes along with an L4 root injury on the right (“Right Side: sciatica lower back into foot; backache, buttock pain, hypersensitivity of the skin down my thigh, sharp outside knee pain”). You have significant L4 root compression and maybe also L5. See https://neckandback.com/conditions/lumbar-foraminal-stenosis-collapse/ and https://neckandback.com/conditions/symptoms-of-lumbar-nerve-injuries/
You need to get a second opinion with another spine surgeon.
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.Thank you, Dr. Corenman,
My neurosurgeon showed me the MRI images showing spinal fluid surrounding the cord (although the white spinal fluid on the image looked pretty thin to me). His office notes state: “She does have spinal canal stenosis at C5-6, but with questionable impingement. In fact, on her recent myelogram CT study, there does not appear to be actual cord impingement.” He also stated he thinks there is a reasonable chance that the myelopathy is unrelated to the cervical stenosis. What else could be the cause?
CERVICAL SPINE CT WITH CONTRAST 7/12/17: “C4-C5: There is solid bony fusion across the left facets and the disc space without midline AP canal diameter narrowing. There is severe left and moderate to severe right foraminal narrowing due to residual uncovertebral and facet arthropathy. C5-C6: There is markedly sclerotic very hypertrophic endplate and uncovertebral changes. There is severe bilateral foraminal narrowing, slight retrolisthesis of C5 on C6 and severe disc space narrowing. There is moderate AP canal stenosis. There is some cord flattening/deformity. There is light retrolisthesis of C5 on C6. C6-C7: There is severe disc space narrowing and severe left ucovertebral arthropathy. There is severe left foraminal narrowing, mild right foraminal narrowing but no midline AP canal stenosis.”
You have my heartfelt thanks for your input; over the past three years I have had multiple MRI’s, two myelograms, x-rays and two EMG/NCS studies (EMG/NCS studies were essentially normal) but no definitive diagnosis.
Did you have a surgical anterior-posterior fusion of C4-5 (“C4-C5: There is solid bony fusion across the left facets and the disc space without midline AP canal diameter narrowing”)? This fusion, whether from surgery or naturally occurring, increases the stress of C5-6. You don’t note motion of C5-6. Did you have flexion/extension films of this level to note motion? You have cord compression at C5-6 also (“There is moderate AP canal stenosis. There is some cord flattening/deformity”). If there is not “severe” compression but there is motion, the cord could get compressed from the abnormal motion but won’t look as compressed on an MRI or CT scan as you are lying down when these scans are taken which would “normalize” the C5 on the C6 vertebra.
With cord signal change at or near the C5-6 levels, I would interpret this finding as an injury due to stenosis. If the cord signal change was at C7-T1 with no nearby narrowing, this could be dismissed as a non-mechanical finding (maybe MS) but cord signal change close to the narrowed segment should be considered mechanical injury.
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.I have never had neck or back surgery. In 2015 neck and lumbar flex/extension X-rays were taken and no motion of C5-6 was mentioned only the spondylolisthesis of L4-5.
The first neurosurgeon I saw diagnosed severe cervical stenosis and said I was at risk of paralysis. He referred me to his partner for neck surgery; his partner ordered the x-rays and said I did not need neck surgery I needed L4-5 surgery. I was told that the cervical stenosis appeared severe until the dye was added (during myelogram) and then it appeared “moderate” (they had to tilt the table to get the dye past L2-3 and into the cervical spine.)
Could the L4-5 spondylolisthesis cause my left side weakness, clonus, clumsiness, etc., in addition to my right side sciatica? These symptoms have slowly worsened over the past three years.
I also have “near total collapse” of my L2-3 disc space with sclerotic endplate changes – would this be a factor (I have been told it is not.)
I am in St. Louis, Mo. Do you think I could get a definitive diagnosis at your clinic?
Thank you Dr. Corenman.
Long tract signs (hyperreflexia, Hoffman’s, Clonus, imbalance, hand atrophy) are an indication of spinal cord compression and myelopathy. The L4-5 level would cause leg pain, weakness of the foot/leg muscles and numbness/pins and needles in the leg.
L2-3 with “sclerotic endplate changes” but no canal compression can cause back pain but no leg symptoms.
If you come into the clinic, you will obtain a definitive diagnosis and fully understand your disorder. I will tell you that it will take at least 1 1/2 hrs with you for one area (either neck or lower back) so to have two separate areas assessed would take two separate days. There are many reasonable hotels in the Vail area that we can recommend. I also have a “long distance consult” where we can deal with these issues over the phone and then if you came in. we could evaluate both areas at once.
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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