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  • SusanB
    Member
    Post count: 3

    hi Dr. Corenman:

    I am a 51 y.o. female in very good health and shape. On 02/01/13 I developed intense pain/spasm in my right upper back, felt it in my right pectorals, going through my shoulder and down my arm, into my index finger. (I believe from doing a yoga pose). The pain initially was quite severe and was of a burning type sensation into the index finger. I used ice/heat, rest, ibuprofen and when I tried to stretch it out a week later, I developed intense pain in my right shoulder and then I noticed weakness of my right triceps.

    I saw my MD, had a short course of steroid taper (which seemed to knock out the pain) and cervical MRI on 2/26/13: C5-C6 bilateral uncovertebral joint hypertrophy with disc bulging marginal osteophyte cause of midline, causing thecal impression more to right than left and at the midline, the AP dimension of the spinal canal as borderline stenotic, right C6 neuroforamen is markedly narrowed, left C6 neuroforamen moderately narrowed.

    At C6-C7 disc bulging marginal osteophyte formation is seen causing broad thecal impression across midline. AP dimension at the midline is minimally stenotic. The right uncovertebral joint demonstrates some spurring as well. The right C7 neuroforamen is moderately narrowed left C7 neuroforamen mildly narrowed.

    Impression: spondylotic changes seen bilaterally and across midline at C5-C6 cause thecal impression left and right, cause borderline spinal stenosis, and cause C6 neuroforamen narrowing right C6, moderate narrowing left C6 neuroforamen.

    Broad thecal impression at C6-7 is also seen, right C7 neuroforamen is moderately narrowed, left C7 neuroforamen mildly narrowed. At C4-C5 a tiny central protrusion is seen.

    A physiatrist on 3/14/13 recommended I have PT, Cervical nerve root block and consult a neurosurgeon. He said I’ll never regain 100% of my triceps muscle strength. He said I may get up to 80%, I am right handed and am a musician.

    I tried acupuncture and after one visit, developed vertigo which lasted for just over a week. It affected my walking but the MD did not seem concerned. It has gone away.

    I had a PT visit and he said my right triceps strength is 3/5 and I had decreased reflex right triceps.

    I have an appointment with a neurosurgeon on 4/09/13. I am trying to schedule the C7 nerve root block, pending insurance issues.

    Currently my right index finger is numb, the side of my middle finger is numb, and my right triceps continues to be weak. I am already noticing loss of muscle tone. My right hand is crampy and typing is laborious but I have to continue to work. I am practicing good posture but my symptoms are persistent. I have noticed some slight left arm/hand symptoms occasionally.

    1. At this point, can a right C7 nerve root block
    take enough pressure off the nerve to avoid surgery or is this just a bandaid/temporary measure?

    2. Is it possible, in time, that the nerve can “unpinch” itself or are aggressive measures needed? Can a good PT and/or an osteopath with manipulations help unpinch the nerve?

    3. Is it true that surgery/decompression does not guarantee that weakness will resolve? What would then be the point of surgery if I don’t have much pain at present? My main symptoms are weakness/numbness.

    4. I have a huge dream trip to Europe planned for the end of July which is already paid for. This seems like terrible timing if I need surgery. If I had surgery say, early May, would I be able to go on this trip? (I will have help with luggage, won’t have to do much heavy lifting).

    I read in one book “Do You Really Need Back Surgery?” that decompressive surgery has become so advanced that can be done as an outpatient procedure with patients back to work in a few days. Is this true?

    If I wait until after the trip (July 26 – Aug 4), that will be going on 7 months, is that too long to wait regarding my right triceps weakness?

    I know without examining me that you cannot answer all of these questions accurately but I do sincerely appreciate your time and expertise!

    Donald Corenman, MD, DC
    Moderator
    Post count: 8465

    You had classic symptoms and findings of a right C7 nerve radiculopathy. The triceps muscle weakness is most likely directly related to the compression of this nerve root. With right triceps muscle strength at 3/5 (normal is 5/5) and you’re being a musician, it is my opinion that surgery needs to be considered.

    An epidural steroid injection will reduce the pain and “tingling” in the arm but will do nothing to reduce the compression on this nerve. This is always the problem with these injections. You might “feel” better but the compression continues.

    With degenerative changes and most likely bone spur compressing the nerve, this nerve will not “spontaneously decompress” over time. Manipulation is contraindicated.

    You are not a candidate for the posterior foraminotomy in my opinion. By the sounds of your MRI interpretation, this nerve compression is due to loss of foraminal height and bone spur due to the degenerative changes of the disc. You would need an ACDF of this level (see website) and possibly the level above depending upon the findings on the MRI.

    It is true that surgery does not guarantee the full recovery of the nerve root function. The surgery is designed to free the nerve of compression. Mother nature has to then heal the nerve. That healing does occur quite frequently but it is not 100% in every individual. There are no studies to determine how long or how severely the nerve can be compressed before the nerve will not recover. See the section regarding nerve injuries to understand why this is.

    It is possible that if you have surgery early enough prior to departure (two months), you can still go to Europe. Much depends upon the surgeon and your initial recovery. Do not wait however to have surgery as regardless of the lack of research, I believe there is time dependency between compression of the nerve and surgery to allow the nerve to recover.

    Dr. Corenman

    SusanB
    Member
    Post count: 3

    Thank you Dr. Corenman.

    As I mentioned, I do not have much pain at this point. Sometimes I feel a slight burning in my right index finger (which is numb) and just tightness in my right upper back. I do have continued weakness, right triceps, and my right hand feels “crampy” especially with prolonged computer work.

    The surgery (ACDF) you think I would need based on my MRI sounds major and risky. I read in a book “Do you really Need Back Surgery” by Dr. Aaron Filler that decompressive surgery has become so advanced that it is done as an outpatient and people are back to work in a few days. Would that be the posterior foraminotomy you are referring to?

    I saw you mention elsewhere that with C7 the nerve is more “forgiving”….so would waiting 6 months be inadvisable (having surgery in August when I return from the trip?) As opposed to having the surgery with a possibly long protracted rehab which will prevent me from going on the trip. I know you cannot predict this with any certainty without examining me.

    Thank you!

    Donald Corenman, MD, DC
    Moderator
    Post count: 8465

    I have not had the opportunity to read this book so I cannot comment on the conclusions but I can tell you that posterior foraminotomy is an outpatient procedure. Nonetheless, it is not an appropriate procedure for many cervical disorders and the indications for this procedure should not be “stretched”.

    The ACDF procedure is a reliable and relatively easy procedure to recover from in most cases. Most patients are surprised after surgery how easy it is to recover.

    You are correct in that the C7 nerve has more potential to recover than C8 or T1 but be careful as this is not a guarantee. Being a musician would make me more cautious about living with compressive dysfunction of this nerve.

    Dr. Corenman

    SusanB
    Member
    Post count: 3

    Thanks again, Dr. Corenman.

    Specifically, I do play instruments but mostly I am a professional vocalist. I do this as part of my living and I am not required to play an instrument. The more I read about this ACDF procedure the more I think it would be quite risky for me to undergo, with the possible resulting hoarseness of the voice that could conceivably last for months. I read on one forum that a woman completely lost her singing voice. By the way, last week my physical therapist said my triceps strength was a 3+/5. I do have a triceps reflex but it is somewhat diminished.

    At this point, two months post injury, is there any other nonoperative treatment that could help? As I mentioned, I do not have much pain at all. Would oral steroids or a stronger oral anti-inflammatory (diclofenac?) be worth a try? Have either steroid or selective nerve root block injections ever been known to calm the nerve down enough to avoid surgery and regain some of the strength back? I have heard that the cervical SNRB can be a risky procedure.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8465

    Theoretically, any procedure can be risky but in the hands of a skilled, meticulous and experienced clinician, the risks are very minimized. You should have some concern if you are a singer regarding the ACDF. The surgical approach to the anterior cervical spine can be made on either side but the recurrent nerve (the vocal cord nerve) is at much more risk with a right-sided approach. Left sided approaches are much more safe.

    For pain and numbness relief, the most effective treatments are steroid injections. These however will not reduce the compression on the nerve so motor strength improvement will not be affected by these injections. This is always the danger with using injections; “feeling less pain” does not mean the nerve is improving but that is how the patient interprets this relief.

    NSAIDs like diclofenac are in the same boat. These might yield some symptomatic relief but will not “decompress” the nerve.

    Dr. Corenman

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