a year past ACDF, new MRI what does it mean?

Tagged: 4 level ACDF with continuing arm pain

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mnjody
Participant

December 19, 2020 at 4:33 am

Post count: 19

#33476

Hi, last December I had c5-t2 ACDF. In the past month, pain has hit me so hard, my left side of my body is just not my friend. I have neck pain, into my shoulder, down my arm in numbness into my hand – all left sided. I recently had an MRI, and here are the results. Any insight?

IMPRESSION:
1. Postoperative findings of the cervical and upper thoracic spine from C5
through T2 levels. Central bulging annulus at C5-6 and to a lesser extent at
C6-7 contributing to moderate canal narrowing at C5-6 with mass effect along the
ventral aspect of the cord at this level. Repeat CT may be helpful for further
characterization if clinically indicated.
2. Multilevel neural foraminal narrowing is also present, greatest on the left
at C4-5 and C6-7.
EXAM: MR CERVICAL SPINE WITHOUT IV CONTRAST
COMPARISON: Radiographs 12/14/2020, previous MRI 12/31/2019, CT 12/29/2019.
FINDINGS:
Skull base-C2: No focal abnormality.
C2-3: No canal or neural foraminal narrowing.
C3-4: Left-sided uncovertebral hypertrophy contributing to mild to moderate
left neural foraminal narrowing. No significant canal narrowing or right neural
foraminal narrowing.
C4-5: Regional hardware-related artifact limiting detailed evaluation. No
significant canal narrowing identified on sagittal imaging. Bilateral facet and
uncovertebral hypertrophy contributing to neural foraminal narrowing, moderate
to severe on the left, mild to moderate on the right.
C5-6: Operative level. Postoperative findings with central bulging annulus with
flattening along the ventral aspect of the cord best demonstrated on image 23
series 6/7, image 7 series 3/5. Overall moderate canal narrowing with retention
of small amount of CSF posterior to the cord at this level.
Uncovertebral hypertrophy contributing to mild left neural foraminal narrowing.
No significant right neural foraminal narrowing.
C6-7: Operative level. Postoperative findings with central bulging annulus
without significant mass effect on the cord, partial effacement of the thecal
sac compatible with mild to moderate canal narrowing. Bilateral uncovertebral
hypertrophy, left greater than right contributing to moderate to severe left
neural foraminal narrowing, mild right neural foraminal narrowing.
C7-T1: Operative level: No significant canal or right neural foraminal
narrowing. Mild left-sided uncovertebral hypertrophy contributing to mild left
neural foraminal narrowing.
Alignment: Within normal limits. Hardware-related artifact limiting detailed
evaluation.
Bone Marrow: No fracture or destructive marrow signal abnormality.
Hardware-related artifact limiting detailed evaluation.
Extra-spinal Findings: No significant incidental findings.

Donald Corenman, MD, DC
Moderator

December 19, 2020 at 11:31 am

Post count: 8660

#33477

First of all, having a 4 level ACDF fusion has a higher chance of pseudoarthrosis (lack of fusion) so immediately, my thoughts start with that possibility. Pseudoarthrosis is best diagnosed with CT scan followed closely by X-rays including flexion/extension.

You have significant foraminal stenosis at C6-7 left (“moderate to severe left neural foraminal narrowing”) so you could have a Left C7 radiculopathy either from a residual compression or a developmental compression from a pseudoarthrosis. See https://neckandback.com/conditions/symptoms-of-cervical-nerve-injuries/

The way I would consider a workup is to have the CT and X-rays, determine fusion status, then use a SNRB at C6-7 left (https://neckandback.com/treatments/epidural-injections-and-selective-nerve-root-blocks-diagnostic-and-therapeutic-neck/) to determine if the C7 root is involved. If the SNRB is positive (gives you temporary relief), then you have two choices.

If the CT scan shows a solid fusion, you can have a posterior foraminotomy. If you don’t have solid fusion, you can have a revision ACDF and clean out the foramen from the front at the same time or have a posterior foraminotomy and a posterior fusion at the same time.

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.

mnjody
Participant

December 19, 2020 at 1:54 pm

Post count: 19

#33480

Thank you for this information. guess I didn’t realize the same issues that I had surgery for – could resurface again a year later. I feel defeated right now.

I had xrays, but not including flexion/extension ones. Nothing abnormal was found on those, all looked good again.

My best hope is for solid fusion, obviously – but if I do NOT have solid fusion, a revision ACDF would take care of it – or are you saying both an ACDF and Posterior surgery would then be the next step?

Do you think if I am only 1 year out – that things could just spontaneously improve yet from the surgery? Or has that window pretty much passed?

Thanks again for your help – it’s appreciated tremendously.

Donald Corenman, MD, DC
Moderator

December 19, 2020 at 2:31 pm

Post count: 8660

#33481

If you have continuing symptoms and pain in the pathway of the C7 nerve root, you can elect to wait but after a year, your fusion should be solid. If it is not, then where is the pseudoarthrosis? A CT will reveal the non-union (along with flexion/extension X-rays). If a pseudo is present you could have revision ACDF, ACDF with posterior fusion or posterior decompression and fusion.

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.

mnjody
Participant

January 14, 2021 at 9:33 pm

Post count: 19

#33533

The CT revealed solid fusion. Impression from CT report: Large posterior bony spurs at c5 and c6.
What could cause those bone spurs to return after surgery? Does having this put me at a higher risk of injury if in a car accident or something, or am I overthinking? Does this happen often, and if so – what is the outcome? More surgery? Could the bone spurs eventually get better/disappear?

I am still in pain – but don’t know where to go from here.

Donald Corenman, MD, DC
Moderator

January 15, 2021 at 8:31 am

Post count: 8660

#33534

If the CT noted solid fusion, then these bone spurs were “left over” from the original pathology. Bone spurs do not increase in size in the presence of a solid fusion. If these spurs do not compress the cord or a nerve root, then they are stable and you don’t need to worry. If your symptoms did not improve after surgery, then you need to ask your surgeon why they did not improve or gain a second opinion.

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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