[exercise453]

#6424

Hi Doc,
Loyal reader…potential visitor

I have read the indications for foraminotomy vs fusion including neck pain vs arm pain. I still do not fully understand. These questions are for c3/4 and c4/5.

You always ask about neck/arm pain percentage to determine foraminotomy vs fusion. C3/4) does not run down the arm and to the hand. Much of its journey is above the base of the neck. You have said it will radiate pain to the base of the skull and across the top of the shoulder. At this high level wouldn’t a symptomatic, unilateral, lateral herniation cause great one sided neck pain. Couldn’t a foraminotomy be indicated for neck pain in this circumstance?…….What about c4/5…same unilateral side?

Where there is a posterior disc (not hitting cord) and also lateral extension, and evidence that suggests the lateral part of the disc herniation is responsible for the unilateral nerve root symptoms, is it reasonable to attempt a foraminotomy in an initial attempt to avoid a fusion. (Images confirming of course)?

Can foraminotomy be performed on consecutive, same side levels(c3/4 and c4/5)?

Wouldn’t different elite doctors answer these questions differently?

Thanks,
___________________________________________________________________

These are two radiologist descriptions at c4/5……(c3/4 is a lateral herniation).
c4/5 posterior disc osteophyte-complex without evidence of cord compression with mild narrowing of the spinal canal. There is bilateral lateral extension resulting in moderate neuoforaminal stenosis. (me….the posterior disc almost reaches the edge of the canal, the cord surrounded by fluid but thin on the disc side. The disc does not contact the cord)

A second radiologist: At c4/5 there is mild disc space narrowing with partial dehydration of the disc. Posterior bulging of the disc is seen with anterior and posterior spurring. There is encroachment on the anterior subarachnoid space and left sided neuroforamen.

[Donald Corenman, MD, DC]

#6425

Foraminotomy vs. ACDF (fusion) has some definite indications for one vs. the other but there are some gray areas.

If the main problem is a radiculopathy (nerve pain from compression), then the main question is- what is causing the radiculopathy? If it is a herniated disc in the foramen only, a foraminotomy will generally work. If the disc herniation is causing the compression and the herniation extends under the spine cord, removing this herniation can put the cord at risk surgically.

If the cause of nerve compression is a bone spur from the facet side (the back of the foramen), a foraminotomy will work. If the bone spur causing the nerve compression originates from the uncovertebral joint in the front of the foramen (the most common location), the foraminotomy is much less successful as the bone spur is very difficult to remove from the back of the neck. The back of the foramen can be opened up but the nerve can still be tethered from the front by the spur.

If the problem is severe narrowing of the foramen from collapse of the disc space, the height of the disc needs to be restored and the only way to do that is with an ACDF. This surgery restores the height of the collapsed disc and therefore restores the foraminal height.

Now- if disc or facet pain is the cause of symptoms, the foraminotomy is not the surgery of choice as this surgery does nothing to reduce motion of the pain segment. The nerve in this situation is not compressed and surgically decompressing the nerve will be ineffective. An ACDF is the surgical treatment of choice to stop the motion of the painful segment.

The artificial disc replacement (ADR) is another option for any herniation at any location that is causing nerve compression and arm pain. This allows segmental motion to continue but removes the herniation compressing the nerve. The question here is how long the implant will work properly? ADRs may work for 25 years or for 10. We do not know at this time. I have revised patients who have come in from other institutions with a non-functional ADR to a fusion without problem so a failed implant can be converted into an ACDF.

ADRs are not indicated for neck pain from degenerative disc or facet disease as the purpose of surgery is to stop motion in this case and the ADR obviously encourgages motion.

Foraminotomies have potential complications as does the ACDF. New onset neck pain from partial removal of the facet and slightly less success rate (less than perfect nerve decompression- remember Payton Manning) are potential problems.

As far as the C3-4 level causing neck and shoulder pain if there is nerve compression present, this nerve can cause these symptoms. Symptoms can even radiate into the front of the chest, mimicing chest pain from a heart attack (cervical angina).

The tools to understand where symptoms originate are the selective nerve root block (SNRB), the facet block and the discogram. If the nerve is the cause, a well placed SNRB will give excellent temporary relief. If the nerve is not involved, the block will give less than 50% relief. The facet block will give the same relief percentage if it is the pain generator. The discogram is the last resort to determine the pain source.

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.

[drjay]

#7069

Hey Doc, I appreciate you and your forum. I wrote a couple days ago, but sent email directly to you– I then received an email directing me to post here. So here it is.
Is bone spur origination predictable via MRI/ X-rays or
clinical game time decision?
We spoke by phone about possible artificial disk replacement, however, you had recommended a select nerve root injection at C7, which is great idea, however I recently have little pain, mostly tingling down left arm, index finger, so I question diagnostic value until pain returns- am I thinking right?
Secondly, am I a good candidate for posterior cervical foramenotomy based on my MRI? Had Mayo recommend it last week.
Thanks,
Jay Segrist

[Donald Corenman, MD, DC]

#7081

Bone spur origination should be obvious via X-ray and MRI comparison. There are rare situations that the origin cannot be confirmed (on MRI- ligament, annulus, bone and old disc hernation are all black signals). If the source of the bone spur is not obvious, a CT scan will reveal the origin.

If you now have pain resolution and only have paresthesias (tingling), you should consider a selective nerve root block as the nerve is improving and the block may take most of the symptoms away.

Please call Margaret at the 888 number to make sure the scans have arrived at the office. I will call you once they are available.

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.

[rotsy63]

#7618

Dr. Corenman,
Great site. If someone has a foraminotomy, does that preclude having disc replacement later on (cervical)? Also I understand that LDR will have a two level cervical disc replacement approved in the U.S. sometime in 2013, do you have any views on that?
I am trying to avoid a two level (c5-c6-c7) fusion due to osteophytes, and bulging discs causing pain in right shoulder blade to hand. Getting a second opinion later this week, and maybe a third if the first two are widely divergent.

[Donald Corenman, MD, DC]

#7620

A foraminotomy does not preclude an artificial disc replacement at a later point if some guldelines are followed. If a degenerative spondylolisthesis results from the foraminotomy or significant neck pain accompanies the foraminotomy, this individual would not be a good candidate for an artificial disc replacement.

The ADR is a procedure I like but there is some evidence that ADR may not be that great in protecting the adjacent level from increased wear.

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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