[BPat]

#8348

The core preop symptoms that led me to surgery are all still there. None were severe/sharp even in preop – just chronic and causing me to not live the active life I had been (I have young kids, work out, in late 30s, etc). After 7mo of drugs, PT and 2 epidurals I was ready to try the PF procedure to “get back to normal”.

The preop symptoms jumped around oddly – those that were most disruptive were largely muscle spasms/ dull aches /the feeling of a knot (mostly around medial border of the scapula) – there 70% of the time, in addition fatigue and some dull aches along the upper paraspinals (this is every once in a while) – only 20-25% of the time but most impactful to life when there.

Less disruptive, I also had preop tingling in the thumb tip – 100% of the time , a dull tingling odd sensation in the bottom of my forearm running down to bottom of my wrist – 50% of time (this, and intensity of thumb tingling, was much more intense 7mo ago at the random onset of these issues – but calmed down considerably over the first few weeks). And maybe 10% of the time I’d feel an ache at the front of my shoulder at the tip. All these symptoms (which jumped around/came&went even preop – largely “going” with help of physio massage), I have felt on&off postop (with the medial border of the scapula aches pretty close to 100% of the time) – 4wks post PF.

New sensations POST op (all mild), incl a sensation/feeling of fatigue in my bicep. Also new is a sensation in my tricep – tricep is odd as while I have “severe formaninal stenosis” at C4, C5 & C6 … C7 is ok. I have of course some post surgery pain in neck but pretty mild/understandable.

I now worry re the underlying diagnosis / treatmnet plan … maybe a PF for C6 was not the right path … only 4wks so trying to balance patience(its early) with reality (no improvement after 4wks)

I will connect re a phone/e-consult
Thanks

[exercise453]

#9347

Dear Doctor,
I’m back on my thread. I apologize for the length which I have avoided for quite some time. I have asked you questions about left side neck pain at c2-3 and c3-4(bulging disc with left lateral extension) and also c4-5 (bulging disc with left lateral extension, no or insignificant weakness) on other threads…(from a fall while jogging 8 years ago) but 6 months prior there was a left side weight lifting trauma in the incline bench press position. I felt a sharp pain and then and for years thought I broke my scapula. It is a certainty that it herniated c7-t1(left paracentral disc herniation causing mild impression on the ventral aspect of the thecal sac and moderate narrowing of the left side neural foramina. No central canal stenosis is seen. There is a 1mm-2mm anterior vertebral offset.) I did not have neck pain from this. This started later, a month or two after that jogging fall so about 8 months later. There is also a prior damaged shoulder.

I started with the doctors 3 years after all this. The herniation was missed back then by the radiologist and spine surgeon and a nerve test implicated the left cubital tunnel for ulnar neuropathy. I was uneducated back then and thought all the weird back, shoulder and arm sensations were shoulder trauma related. I had never noticed the significant atrophy to the interosseous muscles, most notably the missing first dorsal interosseous on the non dominant left hand. I saw an excellent hand surgeon who performed a “much needed” endoscopic cubital tunnel release. I had ignored immense pain from curls for years right at the cubital tunnel so it all made sense. At the time we knew nothing of the c7-t1 hernation and of course there was no benefit from the surgery.

By now I was educating myself intensely and replaying the history. Since this was trauma and not long time degeneration and since I still have a strong grip I came to suspect that maybe it was the T1 root that wasted the intrinsic muscles and coincidentally there is a bulging (not herniated) disc at T2. I do have pain around the c7-t1 and possibly t1-t2 spinous process, it is hard to tell. The hand feels week but is 100% functional .This nerve may have been double or even triple crushed. After this I met Dr Corenman and have read and reread everything and developed a staggering civilian spinal education. Every doctor remarks about it…”I have never had a patient who……. And yet I am unsure about a number of things.
I write this saga now because I just saw an excellent, conservative, 30 years experience spine surgeon/65% cervical surgery. (diagnosis-cervicalgia-primary….Displacement of cervical intervertebral disc without mylopathy…Cervical Radiculopathy) He dismissed the neck pain from c2-5 “we do not chase neck pain…we are good with arm pain, we are not good with neck pain”. He read the mri with me and I gave him an xray with flexion-extension I suspect he read prior. He refused all reports yet did pick up on the vertebral subluxation. He said it was left sided and did not seem bothered by it. He then offered a posterior foraminotomy at the c7-t1 level. He performs the open technique. He said he would try to do something (I forgot what) otherwise he would just remove the disc and decompress the nerve. He quoted an 85%-90% success rate. I intend to get a follow up appointment and find out this and more. It was a long enough appointment but we really did not get down into the weeds as this post does. I do not know if he realizes all the other potential pain generators or if it would matter to him since the mri and physical findings match. I intend to get a follow up appointment and find all this out.

My only issue is pain. Prior to the jogging fall and neck pain I do not think I would have surgery for the arm issues…not bothersome enough, and the hand muscles are long gone. But if this is causing the left inside scapula, across scapula pain, hand weirdness, pain near scapula and sharp pain at scapula, lateral forearm, wrist when moving head forward or back then the surgery might be beneficial. The indications and imaging seem obvious but I am concerned about how much pain is actually caused by this nerve ( I suspect a lot) but with c4 and c5 capable of the trapezius, scapula shoulder stuff, a subluxation, T1 and T2 suspicious and 8 years gone by well?????????? who knows. I know you would recommend an snrb and I would not have the surgery without it. For now, as I inch forward I have these questions for you.

1- I have read all the hoopla about minimally invasive and your comments on it. I understand all (spine) surgery carries risks. Still is a posterior foraminotomy a “minor procedure as it is portrayed to be…(“Peyton Manning underwent a “minor” procedure today”.) Do you consider/Is a posterior foraminotomy a “minor procerure???

2- Does the nerve being compressed concern you? If it is a pain generator can it still heal? Can their still be any hand strength improvement???

3- Does a 1mm-2mm anterior vertebral (subluxation) concern you for a posterior foraminotomy???

4- The doctor spread his fingers about 2 inches and the scar would be down the midline….as Manning has. Precisely where is the scar that you show in your c7-t1 posterior foraminotomy video with the ruler of less than an inch. It seems I may need this identical surgery. Is it midline, off to the side…where???

5- Major doctors like Peyton Mannings doctor and this doctor perform this procedure open. You perform it with the small incision and microscope which obviously seems preferable. I have trouble believing they cannot do minimally invasive. Do they see more or something else…are there different indications or is their no real difference.???

6- If there were two greatest doctors in the world. One did the procedure open and one through the small incision (you). One was in your area, the other involved air travel. Where would you take your family to have a posterior foraminotomy performed. Do you think it is significant enough to travel for the small incision and microscopic method vs the open method???

Many many thanks

[Donald Corenman, MD, DC]

#9348

First- regarding “open vs “minimally invasive” surgery, there is generally no difference in results in the hands of a good surgeon. There is a “sales movement” to push “minimally invasive surgery”. The incision in “minimally open surgery” in the lumbar spine is just as small or even smaller than a “minimally invasive surgery” incision.

In regards to the cervical spine, I do like “minimally invasive” surgery through a tube for the posterior cervical spine as I think this spares the muscle somewhat but a good surgeon who performs this procedure in an open manner should have very acceptable results.It should be noted that this “minimally open” procedure does not work for the anterior cervical spine.

Regarding Peyton Manning, he originally underwent two separate posterior cervical foraminotomies before it was understood that he really needed an anterior cervical surgery (ACDF). This procedure ultimately fixed his nerve root compression.

The posterior foraminotomy does remove 1/2 of the facet on the compression side. If there is a degenerative slip present, the risks of instability and local neck pain do go up. I might consider an anterior surgery in the light of this slip (ACDF).

A posterior foraminotomy with the tube (minimally invasive) requires an incision directly over the facet so the incision is off center. An open procedure requires the incision in the midline to detach the muscles and then reattach them.

I would assume the microscope would be used in almost all cases of posterior foraminotomy.

You are really picking the surgeon and the results that this surgeon can demonstrate. If the results were much better from a distant surgeon, I would certainly travel. If there was very little difference, the local surgeon would be preferable. The problem you have and the question I cannot answer (at least at this point) is who’s results are better. There are no publications and no “rating system” that can discern that answer.

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.

[exercise453]

#9406

Doc,
Given other likely pain generators above, at my (your) insistence I will soon have an snrb at C7-T1 to try and determine how much of the pain is from this herniation and if there is enough significant relief to have surgery.

For the snrb should steroid be injected along with the anesthetic???

Thanks

[Donald Corenman, MD, DC]

#9409

Generally, I like steroid mixed with the lidocaine in the nerve block. This is due to the great anti-inflammatory effect of the steroid. If you gain three or months of relief from the steroid inclusion, you won’t regret it. If it does not work, you have not lost much. The potential risks of the steroid are very low in my 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.

[exercise453]

#9525

Dear Doctor,

How do you recommend the cervical selective nerve root blocks you speak of be performed? Are they from the side of the neck or by entering through C7-T1 and running a catheter up the canal?

Is there any difference in the C7-T1 level (where I need it now) or higher up such as C3-C4?

Thanks

[Author]

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