ACDF Surgery Candidate ?

Tagged: Cervical spinal cord compression and the need for surgery

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taketwo
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November 1, 2020 at 1:05 am

Post count: 4

#33326

Hi Dr. Corenman,

I’m a 30 year old male (from India). I’ve been having experiencing constant (mild) muscle twitches in my right arm for over a year. Went to a few doctors and they diagnosed it as benign fasticulation syndrome. More recently I started experiencing a tingling sensation and twitching in my legs and stiffness in neck. Doctor recommended an MRI of cervical spine. My MRI report –

=============
Findings:
Cervical lordosis is obliterated with mild anterior angulation; however, alignment of cervical spines appears normal.

Height of vertebral bodies appears normal. There is no evidence of any abnormal signal changes noted in vertebral marrow.

Cisterna magan appears normal. Craniovertebral junction appears normal. Clivus appears normal.
C2-C3, C3-C4 and C4-C5: The intervertebral disc space appears mildly hypo intense on T2WI. There is no evidence of any significant posterior bulging of the disc noted. There is no evidence of hypertrophy of uncinate process noted. Bilateral exit foramina appear normal. Spinal cord appears normal in size, shape and signal intensity. Paravertebral soft tissue appears normal.

C5-C6 and C6-C7: The intervertebral disc space appears hypo intense on T2WI. There is evidence of disc osteophyte complex noted.no evidence of any significant posterior bulging of the disc noted. There is no evidence of hypertrophy of uncinate process noted. Bilateral exit foramina appear normal. Spinal cord appears compressed. Paravertebral soft tissue appears normal.

C7-D1: The intervertebral disc space appears mildly hypo intense on T2WI. There is no evidence of any significant posterior bulging of the disc noted. There is no evidence of hypertrophy of uncinate process noted. Bilateral exit foramina appear normal. Spinal cord appears normal in size, shape and signal intensity. Paravertebral soft tissue appears normal.

Impression:
1. Loss of cervical lordosis however, height and alignment of spines appear
normal.
2. Significant degree of discs desiccation with reduced height noted at C5-C6
and C6-C7 levels.
3. Disc osteophyte complex noted at C5-C6 level causing compression of
spinal cord mainly in center with an ill defined T2 hyperintensity (oedema / myelomalcia).
4. Disc osteophyte complex noted at C6-C7 level causing compression of
spinal cord mainly in center and towards left.
5. Exiting nerve roots appear normal.
6. Facets and facetal joints appear normal. No evidence of any intra spinal
space occupying lesion.
=============

The neurosurgeon I’m consulting said I have moderate to severe compression and I’d need ACDF surgery but I can wait for a 1 month and strengthen my neck muscles if it helps in improving symptoms. He also stated that I’m not a good candidate for ADR

1 month later of physiotherapy my symptoms have not improved and I have a new symptom – slight loss in sensation in palms of my hand. Neurosurgeon said its a bad sign and recommended me to make a decision within a few weeks about surgery. Also, he wants a CT scan done before to determine if I need a discectomy or a corpectomy. Corpectomy being more invasive. My physiotherapist on the other hand asked me to wait for another month to finish strengthening my neck muscles. Wanted your opinion on my case and what would be the right course of action ? Can I avoid surgery ?

Thank you !

Donald Corenman, MD, DC
Moderator

November 1, 2020 at 8:27 am

Post count: 8660

#33330

Your report notes; “Significant degree of discs desiccation with reduced height noted at C5-C6
and C6-C7 levels….Disc osteophyte complex noted at C5-C6 level causing compression of
spinal cord mainly in center with an ill defined T2 hyperintensity (oedema / myelomalcia)…. Disc osteophyte complex noted at C6-C7 level causing compression of spinal cord mainly in center and towards left”.

To interpret this, you have significant degenerative disc disease at C5-7, not uncommon. The compression of the spinal cord at C5-6 is significant which has caused cord injury (“ill defined T2 hyperintensity oedema / myelomalcia)” and still some compression at C6-7 is also present.

I agree with your neurosurgeon that you need an ACDF at C5-7 and you are not a candidate for an artificial disc replacement. Do not listen to your physical therapist about “needing more 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.

taketwo
Participant

November 2, 2020 at 7:50 am

Post count: 4

#33337

I really appreciate your feedback Doctor. I had some more questions:

– In your experience how are the outcomes for this procedure ? Online literature tells me that ACDF at two levels results in high probability of adjacent disc degeneration and a rework might be needed in 10 years. Is there a fair probability of me leading a normal life without future surgery ?

– What are possibly some things I should clarify with my neurosurgeon. Is choice of instrumentation something I should be concerned about ? He mentioned using a plastic spacer (with bone powder maybe?) and a titanium cage

– Post operation what are somethings I should do to prevent this from happening again or other levels ? My MRI report mentions discs at all levels in my neck are “mildly hypo intense”. Does this mean degeneration is happening at all levels ?

Thank you !

Donald Corenman, MD, DC
Moderator

November 3, 2020 at 12:52 pm

Post count: 8660

#33343

There is a high probability of a normal life after a two level fusion (ACDF). I’ve performed hundreds of these and patients are generally really happy. There is a 2.5%/year chance of adjacent-level breakdown (ASD) which means in 10 years, you have a 25% chance of needing the next level surgical repair. However, there is a high rate of ASD even if you leave the two levels alone and simply watch C4-5 over 10 years.

I personally don’t like titanium cages as they can easily hide a lack of fusion (pseudoarthrosis) and distort future MRI findings. The use of PEEK (plastic) cages with a titanium coating on the bone interface surfaces is a much better way to go in my opinion. A plate is necessary and I don’t think that the cages with integrated screws are as good as the noted PEEK cage and separate plate.

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.

taketwo
Participant

January 17, 2021 at 7:35 am

Post count: 4

#33549

Hello Dr. Corenman,

Its been more than a month since my surgery which was successful. However, I have a new symptom – gushing noises in my eardrums and more recently a constant ringing noise in my ears(tinnitus). My Doc says its unrelated and recommended me to consult an ENT. Have you come across something like this ?

Donald Corenman, MD, DC
Moderator

January 21, 2021 at 9:23 am

Post count: 8660

#33560

Probably not related to your surgery. I agree an ENT consult would be recommended.

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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