C6-C7 bulge - ACDF or Disc Replacement?

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kshabibi
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August 12, 2014 at 6:41 am

Post count: 17

#11278

Hi Dr. Corenman,

Over the past 1.5 year I’ve been having the following symptoms and it has gradually gotten worse.
– Instability in hand – fine motor movements
– Pins and needles in my left arm and hand
– Cold feeling on my left arm
– General weakness on my left arm and hand (can definitely feel it when trying to lift heavier objects
– left leg is also a little weaker

I’ve gotten multiple MRI’s over this time and the primary finding shows a disc bulge at C6-C7.

The MRI findings are pasted below. Can u look through and help me with the following?

1. I am leaning towards an ADR since I am 37. Would i be a good candidate? One of the dr’s I’ve seen is recommending ADR and another one said ADR is not necessary at c6-c7 since there is not much movement at that level.

2. Can u help interpret the findings below? I am aware of the disc bulge and know what that means but am not sure if any of the other observations are concerning? Would I need multiple procedures to address all these issues? Or is the fusion or ADR good enough?

I appreciate all the time and your professional opinion.

Here’s the latest results from my MRI report:

The C2-c3 interverteberal disc is normal.

There is a small central protrusion at c3-c4 with mild disc bulge, causing mild bilateral neural foraminal stenosis

There is a mild disc bulge at c4-5 without significant stenosis

At the c5-c6 level, there is a left central ostephyte protrusion causing mild central canal stenosis. There is a mild bilateral neural foraminal stenosis, left greater than right.

There is a focal disc protrusion at c6-c7 spanning 7mm in the AP dimension and deforming the left ventral hemicord. There is a mild to moderate left nueral foraminal stenosis and mild right nueral foraminal stenosis as well

The C7-T1 intervertebral disc is normal

IMPRESSION:
1. Left central disc protrusion at c6-c7 with underlying disc bulge, causing moderate to severe central canal stenosis with ventral cord deformity as well as moderate left and mild right neural foraminal stenosis.
2. Left central disc osteophytic protrusion at c6-c6 causing mild central canal stenosis and bilateral neural foraminal stenosis, left greater than right.
3. Mild bilateral foraminal stenosis at c3-c4 related to disc bulge with small superimposed central protrusion

Donald Corenman, MD, DC
Moderator

August 23, 2014 at 7:15 pm

Post count: 8660

#11328

First, the symptoms must match the pathology. Your report notes a “focal disc protrusion at c6-c7 spanning 7mm in the AP dimension and deforming the left ventral hemicord. There is a mild to moderate left neural foraminal stenosis and mild right neural foraminal stenosis as well”.

This C6-7 compression can cause some cord dysfunction as well as nerve root dysfunction on the left. This fits with your symptoms so based upon this short review most likely these symptoms match the imaging findings. A physical examination as well as a thorough history would cement this diagnosis. We will assume that these inquires would match with the findings.

This means you are a candidate for an ACDF or an ADR at the C6-7 level. When then is each indicated and what are the positives and negatives?

An ACDF is the tried and true decompression and fusion that is reliable and permanent. Once the level is decompressed, a fusion will stop the motion between the two segments and this level will never bother you again.

The complaint with this procedure is that there is some increased stress brought to the levels above and below. However, most levels that are fused are already very stiff so that argument does not hold much water.

If a normal level should normally move 20 degrees and prior to fusion moves only 3 degrees due to the degeneration (which is a very common scenario), fusion makes very good sense. Stress transfer is already occurring without any surgical intervention.

Now ADR (artificial disc replacement) is designed to allow motion when implanted. This procedure allows you to decompress the level (take pressure off the nerve root and spinal cord) which is the primary reason for the surgery but preserves motion.

There are caveats. This disc replacement cannot be placed in a situation where the level is so degenerative that there is little motion to begin with. In addition, if there is degenerative facet disease present in this level (the joints in the back of the spine), additional motion of this level (which is the purpose of the ADR) can cause increased pain and premature failure of this artificial disc.

ADRs were designed to reduce the stress transfer to the levels above and below by allowing some motion. This stress transfer reduction by and ADR has not been helpful to reduce adjacent level degeneration. That is, degeneration seems to occur in the levels above and below in the same percentages as if you had an ACDF (fusion).

So what is the benefit of an ADR over an ACDF? Continuing motion of the segment that needs surgery. Is this helpful? The answer is yes as the neck will have more motion that if a fusion is performed. Will the ADR benefit the levels above and below. No. This device does not protect the levels above or below.

Are there any downsides to an ADR. Yes. This is a mechanical device and has a certain lifespan. That is, it will eventually wear our and need to be replaced with a fusion. How long will that take? There is no specific timetable that has been reliable at this point. I have revised about 10 ADRs at this point. Nine were not my own but I have had to revise one of my own.

So is an ADR a good idea? The answer is mixed. If the level that needs surgery is a candidate for an ADR (and in my opinion, only about 20-30% of levels are candidates), then you have to consider the pluses and minuses of an ADR. This device will allow more range of motion but will eventually need to be replaced in a future surgery. It will not preserve the levels above or below.

This is the patients decision.

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.

kshabibi
Member

August 23, 2014 at 7:22 pm

Post count: 17

#11330

Thank u for the detailed reaponse. If u dont mind me asking what were the problems with the adrs u had to revise. I have heard placement of the adr is important.

I uave also bee, having weaknes and minor burning numbness in my left leg. Do u think that is related?

kshabibi
Member

August 23, 2014 at 7:49 pm

Post count: 17

#11334

Also my movement right now is pretty good. The doc took xrays of flexion and he said they were good
My chief complaint is not necesaarily pain but my numbness tingling and weakness.

One umexplained symptom is crunching in my neck when i look to the left and then back to center. It almost feels like bones are rubbing and feels like sometimes something is catching and then releases if i shift my neck certain way. Woukd this be indicatuve of facet joint issue or something else?

Donald Corenman, MD, DC
Moderator

August 23, 2014 at 8:33 pm

Post count: 8660

#11338

The ADRs I had to revise had to do with angulation changes or pain. The bony endplates of the vertebra have to support the metal endplates of the disc replacement. There are times with overload that the vertebral endplates fracture and the disc settles or angles abnormally.

This creates pain due to bone overload or nerve compression. The disc needs to be replaced by a fusion at this point.

I have started to use the Bryan disc lately and I find this disc to have a better design. This disc had shock absorption added which many of the other discs on the market do not have. This disc might hold up better than the others but there is one caveat.

The shock absorption characteristic is brought about by a semipermeable membrane that absorbs water to form the cushion for shock absorption. What the life expectancy for this membrane is still unknown.

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.

kshabibi
Member

August 23, 2014 at 9:09 pm

Post count: 17

#11339

Yeah my dr. Is planning on using the bryan disc. Does thst disc use screws as well? If u personally had the option of going with adr or fusion what would u opt for knowing everything uve seen? Thanks
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Donald Corenman, MD, DC

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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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C6-C7 bulge – ACDF or Disc Replacement?