[T]

#19631

2009- had a C5/6 ACDF due to DD. it resulted in successful pain relief and all associated symptoms without re-occurrence. Then a high speed rear ended collision resulted in aggravation of previous symptoms and several new ones. I’ve completed much PT, facet injections neither of which helped. I received nerve root injections at c4/5 level that has helped alleviate much of the pain.

Below Last year MRI Myelogram and this year recent consultations to provide background post accident. Thanks.

Post accident MRI
• Straightening of Lordosis.
C4/5: narrowing of disk, mild DD, Minimal Posterior Bulge accentuated by loss of lordosis indicate Deformity of Anterior Cord’s Margin without stenosis. ACDF C5/6 artifact obscures the anatomy, no posterior is suspected.
• C6/7: Posterior Bulge without cord contact. Final: C4/5 posterior bulge accentuated lost lordosis, and anterior deformity of cord margin indicates C4 retrolisthesis. C4/5 Herniation and Cord Enchroached, C5/6- ACDF- bony overgrowth causes Cord Encroachment.
C6/7- Herniation without any Cord Encroachment.

Myelogram:Revealed Extradural Lesion at C5/6 with Thecal Sac Compression.
Spur projecting from posterior border of C6 with small ventral abnormality.

Doctors notes: 1) FER and DTR
Flexion Extension Rotation over several months… Only have 4 Months of notes but more than 1+ years worth.
Month 1: 70 flexion/ 70 right left rotation. Month 2: right left rotation 50. Month 3) Normal Flexion documented, abnormal extension and abnormal rotation. month 4) flexion 40, extension 50, rotation 60. Motor strength over entire duration 5/5 with the exception of grip strength 4/5.
B) DTR compared over several months Triceps, Biceps, Brachioradialis
Month 1) triceps 1+, Bicep 1+
Month 2) tricep 1+, Bicep O left, right Bicep normal. Brachioradialis 0 absent both left and right. Month 3) absent bilateral Bicep and bilateral brachioradialis. Month 4: Normal Tricep, normal Right Bicep and Right Brachioradialis but absent left Bicep, absent left Brachioradialis.
Injections helpful received only at c4/5 improve pain some, but should surgical consideration be considered doctor mentioned: both levels would need to be fused c4/5 and C6/7 though suggests future injections for pain management as his preference..

My 5 question is
1) your insight or recommended resolve.
2) what’s next? what’s best?
3) is doing nothing just repeat injections the answer/ or a multi level fusion- pros cons given symptoms since 1+ years continued to grow in severity? 4) how might it be possible that symptoms at site of ACDF can reoccur and what can be done at that site if anything? 5) absent Brachioradialis and Bicep on one side, what that means how that can be corrected? Or will things worsen?

[Donald Corenman, MD, DC]

#19749

First I will assume that you have a solid fusion at C5-6 as a pseudoarthrosis (lack of fusion) would change this discussion.

The change in reflex at the biceps and brachioradialis should not occur with a solid fusion at C5-6. I will assume that the “change” is really more from the examination technique than any new problems at this level. A solid fusion with good results should not deteriorate over time.

You certainly could have injured C4-5 and C6-7 in this high speed accident. I will assume that you have had at least 6 months (and it sounds like a year) worth of treatment with continued failure to improve.

If you continue to have neck pain (sand not arm pain) as your predominant symptom, you could consider facet blocks at this time (see website). Good results could lead to rhizotomy (or ablation-same thing) and avoiding surgery.

If you have neck pain as your predominant symptom, you have failed all therapies including facet blocks and you are significantly impaired from these symptoms, you could undergo a surgery workup (another ACDF). This might mean cervical discograms (see website) or highly specific blocks (SNRB-website) to localize the pain generators.

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.

[T]

#19751

Dr Corenman.
Thank you so much for your response.
I do have a solid fusion at C5/6 for years prior to this accident, I’m not sure if absent Bicep and branchioradialis and changes given new MRI suggest that it’s not so solid post the accident?
I’m assuming absent Bicep and brach have to do w that level after all?

You mentioned facets and nerve block injections for which I’ve tried both. The facets on any level tried did absolutely nothing. The nerve block at the C4/5 helps cut the pain down by 50% but that’s it given the severity of the accident my question is

2 options:

A) will a multi level fusion at the sites above and below be necessary since my range of motion is already very impaired even with pain improvements, and I don’t want to continue to further this damage being so young by doing it bandaid style with nerve blocks every few months.

B) I can continue w nerve blocks so long as things beyond just pain control resolve as a result of that or at least don’t continue to worsen over time?

Any final recommendations given I clarified some of what you mentioned would b more than appreciated. Thank you kindly.

[Donald Corenman, MD, DC]

#19758

The only reasons to do cervical spine surgery are nerve compression that causes weakness, spinal cord compression, deformity that is progressive (the abnormal curve gets larger and is harder to correct) or pain that is not tolerable. The most common reason for surgery is the latter. This also seems to be your case. The question is then whether your pain is tolerable or not?

If you use nerve blocks and your pain is tolerable, you could continue to use nerve blocks. It may well be that these become ineffective over time but many patients I have out years continue to use them to great effect.

I can’t tell if you need a multi-fusion as the pain generator might only be one of the two levels. A further work-up might be in order.

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.

[T]

#19935

Thank you Dr Corenman
That truly does help.
There was one other thing I failed to mention that I’m puzzled by, and would as always appreciate your input.

I’ve had 2 courses of nerve block injections. Spaced 5 months apart so far. So as you know C4/5 and C6/7 are two new sites of damage caused by the accident as is the seeming changes at my c5/6 fusion. At any rate both the new levels of damage at c4/5 and c6/7 have worsened with time though I’ve received some good/ moderate pain relief with these injections.. My question is my pain doctor has only been injecting the C4/5 level and only on the right side for each of these 2 injections received. He states my symptoms are more C4/5 based and right side Bc my pain is predominantly on the right and affects my range of motion to the left.. That said while I’ve gotten good relief though less relief with this second injection at the same level and same side, I’ve noticed one consistency: that with both these times I receive an improvement in the first week or two then right after the two week mark or directly before two weeks I have terrible symptoms worse than before the injection debilitating that always last approx 2-3 days than subsides for the duration of treatment. My questions:
1) Is that normal that at or soon after 2 weeks I would have returning more so worsening symptoms for a couple days? 2) If not what could that be attributed too?
3) What could the implications of this mean?
4) both adjacent levels being impacted yet injections received at only one level and only one side- what results or implications can be derived in this approach, what to look for? Why or why not inject both sides and both levels?? 5) If so under what circumstances?

Thanks as always. My apologies for not stating this sooner, as its of great concern!! Thank you

[Donald Corenman, MD, DC]

#19939

The injections contain two different medications, a numbing substance (lidocaine or marcaine) and a steroid. The steroid does not work for at least 12 hours and typically can take 24-48 hours to be effective. Relief “long down the road” (24 hours or later) after an injection will do nothing to help understand what the pain generator is. I could inject steroid into your thigh and you would feel better in your neck in 24 hours.

The key to diagnosis is the “numbing effect” of the lidocaine. This lasts 3 hours and is similar to your experience in the dentist office where he or she will inject this substance into your jaw and the jaw “goes numb” for three hours. This is the exact effect that I am looking for after an injection. This is why I harp so much on keeping a pain dairy.

If the numbing agent is injected into the facet and temporary relief is obtained, this allows us to know that the facet is at least partially involved with pain generation. A selective nerve root block only anesthetizes the nerve root (and partially the back wall of the disc). This will give an indication of pain generation of only these structures.

Relief that lasts days to weeks after an injection really is not too specific and is not prefectly reliable to make surgical decisions based upon the results.

If your symptoms return within two weeks of the injection, this simply means that the injections are not going to be effective to control your pain. There are no other implications.

You could have both levels injected at the same time. This would not be diagnostic but might give you longer relief.

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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