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  • CowboysFan
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    I am a 47 year old male who had an ACDF at C5-C7 in March of 2011. I have had pain for two years now since surgery with some symptoms that I did not have prior to surgery. I am now starting to look for a second opinion on my issues.

    I had severe spinal stenosis at C5 through C7 with a spinal canal measurement of 5mm at each of those two levels pre-surgery. Prior to surgery, I suffered from headaches, right shoulder pain, right arm and elbow pain and occasional numbness in some of the fingers in my right hand. I had a stiff neck and had lost range of motion when turning my head from side to side over a 12 month period prior to surgery. Given that I was at risk of severe injury due to my severe stenosis, I had the surgery.

    For 6 weeks after the ACDF surgery during my recovery, all my pre-surgical pain was gone and I had regained quite a bit of my range of motion when turning my head from side to side. I felt better than I had in a year or so.

    I work from home and my work requires me to lift boxes occasionally that weigh up to 40 pounds and I also sit at a computer for short periods of time during the day. My neurosurgeon indicated to me that I could try any physical activity that I wished and if it caused pain to cease the activity. I did not have any incident of acute pain while performing any of these activities, so I felt I was fine to continue my normal physical activities.

    After I returned to my work, I started losing range of motion in turning my head from side to side, my neck and shoulder muscles have tightened up and the headaches returned. The headaches I have are worse than they were prior to surgery.

    A few months after that, I started having pain and weakness in my upper left arm in the deltoid muscles, which was a symptom I never had prior to surgery. Occasionally, I have similar pain in the right arm, but the pain is predominantly in the upper left arm.

    Since the onset of pain, I have tried many, many treatment options and none have brought relief. I have tried physical therapy, massage, cervical traction, Feldenkrais movement therapy and trigger point injections (in my neck muscles and trapezius muscles). My physical therapist, who is a licensed chiropractor tried two chiropractic adjustments on my neck, also.

    None of these treatments have worked. The stretching done in physical therapy seemed to irritate my neck and shoulders and I found that my left upper arm and shoulder were getting weaker while doing push ups and lifting 5 pound weights. The traction caused my upper arm and shoulder to ache and the trigger point injections gave me about 10 minutes of relief before my muscles tightened up again.

    I did try a 12 day course of prednisone and had a slight decrease in pain during the first day of the course of taking it, but after that the pain went back to its previous level during the remaining 11 days of the course. I did try to take NSAIDs, but I am allergic to them, as I unfortunately found out when trying to take Diclofenac.

    The physical therapist that I worked with sent me to a pain management doctor for some diagnostic injections. I had facet nerve block injections (done at C4-C5), radiofrequency ablation in facet joint nerves (done at C4-C5 and C7-T1), epidural injections (interlaminar injection done at C5-C6), facet joint injections (done at C4-C5). None of these brought relief. The facet nerve block injection dropped my pain level a point (on a scale of 10) for part of a day, but I am not sure if it was the block that did that or not.

    The only diagnostic injection that I have not had is a discogram, to see if I have some internal disc disruption. My neurosurgeon seem to believe that the test is of limited value in addition to being painful.

    I had 3 MRIs and a CT Scan (post myelogram) in 2012. My neurosurgeon states that the fusion is rock solid.

    A week ago, my neurosurgeon has indicated that there is nothing that he sees in any of the imaging tests that indicated that surgical intervention would help me and that there is nothing further that he can do for me at this point time. He has mentioned that possibly I am still in the healing phase after the ACDF and possibly I am a slow healer. Just so you know, my neurosurgeon does not read any of the reports from my imaging tests and looks at the images himself.

    At this point I have no idea what is causing my pain or what to do about it. I am under the care of a pain management specialist who is able to keep my pain level around a 3/10 most of the time with pain medication (Fentanyl patch, Neurontin and Norco for breakthrough pain). Without the pain medication, my pain level would range from 5/10 to 7/10, depending on how physically active I am.

    Symptoms:

    Daily headaches that start from the occipital region on the left side and extend to above left ear and to the left temple.Occasional pain in the back of my neck on the left side. The same type of pain occurs on my right side 1-2 times a month and when that occurs, the pain is worse than when it is on the left side.

    Deep, dull, gnawing ache in upper left arm in the anterior and lateral deltoid muscles. Pain only goes 1/2 way down the arm toward the elbow. Occasionally pain in the posterior deltoid muscle on the left side. There is no numbness or tingling, just pain. I occasionally have the same pain in my upper right arm.

    Weakness in upper left arm and shoulder. I am not able to lift my left arm above my shoulder or head without pain and the deltoid muscles feel weak and tight/restricted when I try to do it. If I try to do push ups, my left upper arm and shoulder is weaker than the right side and the left upper arm and shoulder tires quickly. I am not able to brush my hair on my head using my left arm because of the pain and weakness in my left arm.

    My pain distribution is roughly 60% head/neck and 40% upper arm in deltoid muscles.

    Stiff neck muscles all the time and a big knot in the center of the right upper trapezius muscle. The center of the left upper trapezius muscle is also very tight. These muscles rarely hurt.

    Loss of range of motion when turning my head fro side to side. I seem to have less range of motion when turning my head to the left than when turning to the right.

    The more physically active I am, the quicker my neck muscles tighten up and less range of motion I have turning my head and headaches become worse. I do get muscle spasms occasionally when this happens and my neck feels like it “catches” when turning my head from side to side after being physically active.

    When I have my head down for a few minutes, pain increases, neck muscles tighten up and range of motion decreases.

    When I try stretching exercises my neck and shoulder muscles, my upper trapezius muscles tighten up and ache. At this point, there are no stretching exercises help loosen up my neck and shoulder muscles.

    When my pain is at its worst after being physically active, the muscles at the top of my shoulder blades ache. When that happens, most often it will be on the left side.

    Occasionally feel off balance to my left, like I am falling off to that side and I use right arm to steady myself or right leg. Occasionally bump into doorway frames and other items. I occasionally drop things that I am holding with my left hand. I do not know if that is a symptom of a problem in my neck or because of the medications I am taking.

    I was told by a physical therapy person that I walk very stiffly.

    Imaging History

    (1) MRI Results (January 2012) – My neurosurgeon felt that this MRI had too much artifact in it when he looked at it, so he had me do a CT Scan/Myelogram a month later

    Findings:
    The alignment of the spine is normal. There has been prior anterior fusion fixation at C5-C6 and C6-C7.

    At C2-C3, there is no focal disk protrusion. The canal is broad. The cord is normal in appearance.

    At C3-C4, there is a small uncovertebral osteophyte narrowing the right foramen. There is mild facet arthropathy. The AP dimension of the thecal sac is about a centimeter.

    At C4-C5, there is a broad-based central osteophyte with uncovertebral osteophytes. There is mild facet arthropathy. The AP dimension of the thecal sac is about a centimeter.

    At C5-C6, there has been anterior discectomy fusion. There is some artifact related to metal. The AP dimension of the sac is about 9 mm. There is foraminal narrowing, which is slightly worse on the right.

    At C6-C7, there are small uncovertebral osteophytes. There has been anterior fusion. The AP dimension of the canal is about 9 mm. There is facet arthropathy.

    At C7-T1, there is no focal abnormality.

    Impression:

    The patient has had prior fusion at C5-C6 and C6-C7. There are some central osteophytes. The overall dimension of the spinal canal is small on a developmental basis. There is mild canal stenosis at both C5-C6 and C6-C7 without definite lateral disc protrusion or foraminal narrowing.

    (2) CT Scan Post Myelogram Results (February 2012)

    Findings:
    There is evidence for anterior cervical decompression and fusion with plate and screw hardware fixation at C5-C6 and C6-C7. No asymmetric root sheath effacement was detected on initial fluoroscopic views.

    No instability was elicited with flexion or extension.

    CT images reveal normal position of cerebellar tonsils. The relationship of C1 to the occiput is within normal limits. The C1-C2 relationship is preserved.

    No focal disc protrusion or asymmetric foraminal narrowing is detected at C2-C3.

    At C3-C4, there is mild disc bulging and osteophyte slightly flattening the ventral subarachnoid space. There is mild asymmetric right foraminal encroachment related to uncinate spondylosis.

    At C4-C5, there is central disc protrusion mildly effacing the the ventral subarachnoid space, and there is mild asymmetric right foramina encroachment related to uncinate spondylosis.

    The spinal canal is centrally decompressed at C5-C6 and C6-C7. The hardware appears intact. The fusion grafts appear in position. There is bilateral foraminal encroachment related to uncinate spondylosis at C6-C7.

    No focal disc protrusion or asymmetric foraminal narrowing is detected at C7-T1.

    The cord caliber is within normal limits throughout the cervical spine.

    (3) MRI Results (October 2012) – Neurosurgeon decided to have me do another MRI since I had no improvement since the CT Scan/Myelogram in February 2012.

    Findings:

    There are postsurgical changes from previous anterior discectomy and fusion of the cervical spine at C5-C6 and C6-C7 which are stable. There is some metallic susceptibility artifact anteriorly in the spinal canal at the C5-C6 level. No metallic foreign body is identified in this location on the previous CT scan.

    Alignment is normal. No spondylolisthesis. Signal within the marrow spaces is normal.

    At C2-C3, no significant degenerative changes. No spinal canal stenosis or neural foraminal narrowing.

    At C3-C4, a small uncovertebral osteophyte results in mild foraminal narrowing on the right. This is stable. No spinal canal stenosis.

    At C4-C5, a small uncovertebral osteophyte results in very mild foraminal narrowing on the right. This is stable. No spinal canal stenosis.

    At C5-C6, there has been anterior discectomy and fusion. There is some metallic susceptibility artifact anteriorly in the spinal canal limiting the evaluation of the spinal canal at this level. There is some residual spurring in the central and right paracentral zone which is stable from the previous CT. There is some mild asymmetric foraminal narrowing on the right which also appears stable.

    At C6-C7, there has been anterior discectomy and fusion. No significant spinal canal stenosis and no significant foraminal narrowing.

    At C7-T1, there is a small central protrusion without spinal canal stenosis. No neural foramina narrowing.

    No abnormal signal within the spinal cord. No paraspinal masses. No significant spinal canal stenosis. There is some mild foraminal narrowing at a few levels as described above.

    (4) Upright MRI (Fonar) Results (December 2012) – I asked my neurosurgeon if we could do a more dynamic image with my neck in a weight bearing loads to see if it would show anything (despite the Fonar using a weaker magnet than a recumbent MRI).

    Techniques:
    MR images of the cervical spine were obtained in sagittal and axial planes without IV contrast using multiple imaging sequences. Sagittal T1 and T2 and axial T1 and T2 images were obtained with the patient in erect position. Sagittal images were also obtained with the patient sitting with the neck in a neutral position. T2 flexion and extension sagittals were obtained with the patient in a sitting position.

    Findings:
    Evidence of anterior fusion is seen at C5, C6 and C7. Vertebral alignment appears normal. Craniovertebral junction appears unremarkable. There is no evidence of instability in the flexion and extension views.

    Axial images show no obvious abnormalities at C2-C3.

    Mild concentric disc bulge is seen at C3-C4.

    Spinal canal stenosis is sent at C4-C5 with concentric disc bulge and posterior ligament hypertrophy. The CSF space is erased anteriorly by the bulging disc. Minimal flattening of the cord is also seen at this level.

    Details at C5-C6 are obscured by artifact from the metal. Sagittal images show spinal canal stenosis also at C5-C6.

    No significant abnormalities are seen at C6-C7.

    There are no disc herniations. The cervical spinal cord shows normal signal.

    Impression:
    Postsurgical changes with evidence of anterior fusion C5 to C7.
    No evidence of instability in the flexion and extension images.
    Spinal canal stenosis at C4-C5 and C5-C6 levels is seen.
    Bilateral foraminal stenosis at C3-C4 and C4-C5 levels is seen.

    I did take a look at the images of this test and it looked like the width of my spinal canal at C4-C5 is 7.5mm to 8.0mm when my neck is extended.

    My neurosurgeon has had a couple of X-rays done on me in flexion and extension view and he has said that he does not see any instabilities in my neck. I do not have any written reports for the X-rays.

    Given all the information that I have provided above, would you be able to give me your opinion what is causing my problems or what I should try next? If it would be helpful, I could send you copies of any MRIs or X-rays that I have had taken.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    Wow-you are thorough. I can give you some direction of possible pathology that could be causing your symptoms.

    Developing pain somewhat after surgery that made you feel better leads to two possible diagnoses. One is pseudoarthrosis or the lack of fusion at the levels. Your CT report does not note “solid fusion” but does note “The fusion grafts appear in position”. This is not the same as solid fusion and is ambiguous as to the state of the grafts. If that CT was some time ago, consideration of a new CT should be made.

    The other is aggravation of a preexisting problem at the levels above and below. The pain and weakness of the deltoid muscle region on your left fits with foraminal stenosis of C4-5, the level above the fusion. The comment by the radiologist “C4-C5, there is a broad-based central osteophyte with uncovertebral osteophytes” does not comment on the narrowing of the foramen which I would imagine would not be mild in this level. A selective nerve root block (SNRB) might be helpful to diagnose this condition.

    Headaches I have found can be the result of facet degenerative changes at C2-3 and C3-4. These levels might have been irritated by the fusion of the levels below or preexisting problems which just “felt better” under the influence of medications taken in the post-operative period.

    Don’t forget that pain and weakness of the shoulder could be from a shoulder disorder (rotator cuff syndrome) and that needs to be ruled out too. A trip to a well experienced spine surgeon might be very helpful to you.

    Dr. Corenman

    CowboysFan
    Member
    Post count: 19

    Hello, Dr. Corenman. I cannot thank you enough for the extremely quick response.

    Thank you for your thoughts. If you do not mind, I have some more questions:

    (1) That is a good point about pseudoarthrosis that I had not considered because my neurosurgeon insisted at the time of the CT that my fusion is rock solid and I took it as the gospel.

    The CT that I had was performed 11 months after my ACDF was performed. My neurosurgeon did look at the CT himself and declared the fusion solid. The radiologist’s report does seem ambiguous, as you stated. I did not catch that on my own all this time how the radiologist wrote those comments.

    My question is, how likely is it that the fusion was not solid after 11 months? My surgeon used two plastic discs filled with bone material and did not use an autograft or allograft. I did wear an electric bone stimulator for 4 hours a day for 4 months after the surgery.

    If the fusion is in doubt and a new CT should be made, do I need to do the CT in conjunction with a myelogram or can it be done without a myelogram?

    (2) In regards to the potential facet degenerative changes at C2-3 and C3-4, what would be the diagnostic testing that would be performed on those higher levels to see if that is the problem and what would be the course of treatment if the diagnosis indicated that I have facet degeneration and it is the cause of my pain? I am allergic to all NSAIDs, so if inflammation of those facet joints were the issue, that course of treatment would be a non-starter for me.

    (3) Should I try to rule out a shoulder disorder (rotator cuff syndrome) before seeing an experienced spine surgeon and if so, what kind of physician should I see and what kind of imaging would be needed on my shoulder?

    (4) Are the upright MRI images worthless because of the weaker magnet that the Fonar machines use? There were some comments in the radiologist’s report that concerned me:

    “Spinal canal stenosis is sent at C4-C5 with concentric disc bulge and posterior ligament hypertrophy. The CSF space is erased anteriorly by the bulging disc. Minimal flattening of the cord is also seen at this level”

    and

    “Spinal canal stenosis at C4-C5 and C5-C6 levels is seen.
    Bilateral foraminal stenosis at C3-C4 and C4-C5 levels is seen.”

    (The radiologist’s report is contained in my initial post.)

    (5) Would you be willing to look at any of imaging that I have had already done and would it be worth it? If so, I would be happy to electronically transfer them to you and if you do not have that capability I could mail/UPS/FedEx them to you.

    Please note that I have had two flexion/extension X-rays, one CT scan post-myelogram and 3 MRIs done in 2012. The details of each of the 3 MRIs is in my original post.

    Again, thank you so much for your time.

    Michael

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    A lack of fusion with the use of PEEK cages and no autograft or allograft is not uncommon. The PEEK cages are made of plastic and are not biologically active. If a new CT is ordered, it does not need to be made with contrast or myelography.

    If the C2-3 and C3-4 facets are causing your headaches, facet blocks would be the test of choice to determine this. You would need to keep a pain diary (see this section on the website). If the facets are determined to cause the headaches, then treatment may just need to be facet blocks at various time intervals or rhizotomies.

    If you want to rule out a shoulder disorder, you would need to see a spine surgeon. These surgeons come from the orthopaedic background and have had significant shoulder diagnostic experience.

    The Fonar MRI machines yield poor images and are not very effective for a surgical diagnosis.

    I would be happy to look at your images if you would like to Fedex them to my office. It might take a little time for me to get back to you. You can call the 888 number for further information.

    Dr. Corenman

    CowboysFan
    Member
    Post count: 19

    Thank you so much for offering to look at my images. I will send them soon and make sure to note my forum screen name in the package that I send so that we can continue the conversation here, if that is appropriate.

    If I were to schedule a visit to see you in the future, generally how long are appointments scheduled out? Also, would you do imaging and diagnostic testing at your location or would I do some of that where I am located? I live in Ohio, so I am curious as to how the logistics would work.

    Best regards,
    Michael

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    Please call the 888 number or the office number (970) 476-1100 to talk to one of my nurses. They can give you all the details regarding an office visit.

    Dr. Corenman

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