[Lisa1979]

#26797

Dr. Corenman – Hi! Im a registered nurse, 38 year old female healthy, non smoker, no non-drinker. active, BMI 20. No other contributing health problems.
I had a C6/7 fusion 2013. post-op No complications, recovered well and was 90% fused at 6 weeks and fully fused at 3 months. went back to running, biking swimming without problems.
Fast forward to 2015. 2 car accidents 90 days apart, I was passenger both times. Sharp left shoulder/axilla pain, heavy arm feeling, and burning nerve pain down both arms along with neck pain. I tried PT, massage, injections and even an ablation at c 5/6 the year prior to surgery (2015-2016) symptoms progressed and then I required another fusion 13 months ago, Sept 2016, at c5/6 for a ruptured disc. Same surgery, and same method, same surgeon that did the 2013 ACDF. He is an Experienced Neurosurgeon that I work with at the hospital. He used a Cadaver bone with plate and screws. No hard collar and no bone stimulator post op. He did allow NSAIDS at 6 weeks, which I used.
I had some relief post op for maybe 2 months, arm pain never fully resolved. Progressively in the 4-8 months that followed the 2016 ACDF: symptoms increased to sharp neck pain and sharp shoulder pain and burning arm again – same symptoms as before surgery. Limited ROM, can’t lift beyond 5 pounds without increased symptoms and requiring pain meds to function. The surgeon had discharged me from his service as he said my neck looked stable on xray and released me to work again at 3 months post-op as a nurse and lifted weight restrictions.) With these continued symptoms, I took my self to another surgeon at 9 months post op (July 2017) and was diagnosed with a non-union via CT scan.
I don’t know how to get this fixed. I have now seen 4 surgeons, 2 neurosurgeons, 2 orthopedic. one says a non invasive “DTRAX” method (posterior facet cages), one says repeat another ACDF with my own bone and 2 say posterior fusion with rods and screws. I am really having a hard time knowing what to do. Please help
MY questions: How do I proceed?
1) Will another ACDF compromise swallowing and possibly lead to vocal cord problems? I have mild swallowing problems now.
2) Will posterior surgery cause permanent muscle pain (As 2 surgeons have said it would, that it was “a brutal surgery” Will it cause permanent pain with posterior cervical muscles?

I’m extremely limited in life right now. Im young and can’t due anything due to pain. I want to be able to return to biking, swimming, working out, and working full time as a neonatal nurse.
I’m leaning toward the posterior surgery, because the surgeon that I last saw in Seattle (on Monday Nov 6th 2017) says its the tried and true method for revision of a non-union.
Please given me your advice. Thank you!
Lisa

[Donald Corenman, MD, DC]

#26804

You have a common scenario. You have a pseudoarthrosis at C5-6 above a previous fusion at C6-7. The technique of using an allograft (“He used a Cadaver bone with plate and screws”) has a higher non-union rate but is an accepted technique that unfortunately did not work. You can fault the neurosurgeon for discharging you from care as your symptoms were typical for a nonunion and he did not follow through.

Your symptoms “increased to sharp neck pain and sharp shoulder pain and burning arm again – same symptoms as before surgery. Limited ROM, can’t lift beyond 5 pounds without increased symptoms and requiring pain meds to function” are typical for a pseudoarthrosis. Finally, you found a surgeon who finally diagnosed the real problem (“was diagnosed with a non-union via CT scan”).

You don’t mention any foraminal compression but by your symptoms, you probably still have foraminal stenosis. That might change the surgical equation. The second opinions “one says a non invasive “DTRAX” method (posterior facet cages), one says repeat another ACDF with my own bone and 2 say posterior fusion with rods and screws” are all over the place. I would eliminate the DTRX immediately as this is silly as a solution.

Without reviewing the new CT scan, and assuming that you still have foraminal stenosis based upon your arm pain, I would vote for a redo anterior fusion and decompression with your own bone. This will address both the nerve compression and the lack of fusion. The Seattle surgeon was correct in that a posterior fusion will almost always cause the anterior surgery to fuse but addressing the nerve compression (again-hypothetical) posteriorly is much less successful. Yes-muscle pain post-operatively is more common with a posterior fusion but dysphagia is not uncommon with an anterior approach. Both generally will fade away in 3-6 months.

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.

[Lisa1979]

#26813

Hi Dr.Corenman
I want to express my deep appreciation for your response and insight into this problem.
If I may borrow a few more moments of your time, some other questions came up since your response.
Regarding your question on possible stenosis: My Oct,21/2017 ct scan indicated: No significant central canal or foraminal stenosis at any of the levels.
That being said would you still vote anterior?
Are there any diagnostic tests or injections that would help determine which entry would be the best for this revision? If I got at C-5/6 facet injection and that completely alleviated the arm pain, would that indicate that a posterior entry/revision would be the best method? (A couple of weeks ago they already did the c56 nerve block with no arm pain relief)
Secondly, I’ve had two of the surgeons mentioned that anterior approach would not the best method. Reasons: both said I don’t scar well and that the scar would be much more noticeable as well as the swallowing problems and vocal cord issues. In your experience, both the vocal cord and any swallowing problems are temporary? Both of them made it sound like they could be permanent problems.
If I opt for revision with another ACDF, but this Time using my own bone, How common is chronic hip pain from that incision site? From what I have researched, statistics are pretty high with hip pain following?
How long should I avoid NSAIDs after a revision? Statistics are all over the map with this, anywhere from avoiding them only the first six weeks to avoiding them for up to a year +.
What is your opinion on a bone stimulator and hard neck brace? Are they necessary? Are they helpful? The surgeon in Seattle who is leaning towards posterior says he would not put me in a neckbrace. It was also not ordered after my first two ACDFs.
Lastly, how long can I wait this out? In your opinion, is there any chance of the non-union healing or improving on its own? (my last CT was October 2017 and showed no further bone growth in the last three months) And would there be permanent nerve damage the longer I wait? (My EMG was not terribly bad.)
Any thoughts on why my neck didn’t fuse?
I’ve been avoiding working out at the gym and swimming; at this stage in the game, with a non-union, is it OK to pursue those activities or not? I certainly do have increased pain with it.
Again, thank you for your time and attention to this, it’s greatly appreciated
Lisa

[Donald Corenman, MD, DC]

#26863

I am worried about your continued arm pain. If this pain is a significant portion of your total pain complaint, a work-up needs to be completed to determine why this pain continues. If this pain is only in the shoulder region along with neck pain, this could be referral pain that could be generated only by the non-union. With a complete work-up that rules out nerve compression, a posterior fusion would be a good surgical plan.

Facet injections in the face of non-unions are worthless. You are trying to find the pain generators and want to rule out nerve compression as a source. If there is no pain generated by nerve compression, either a revision anterior fusion or a posterior fusion would be acceptable.

A neck brace at this point would be superfluous. A bone stimulator probably would not be worth-while. After a posterior fusion, I place patients in a neck brace for at least 6 weeks as the posterior construct is not as stable as an anterior construct.

If your neck doesn’t hurt too much with activity and your neck is not unstable (as demonstrated by flexion/extension X-rays), I encourage activities (but not contact sports).

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.

[Lisa1979]

#26888

Thank you Dr. Corenman,
1) you mentioned the importance of diagnosing where the pain is coming from with a work up, To rule out nerve compression.
A month ago I had a c 5/6 nerve block – that did not get rid of the arm pain. Is there something else that can be done to diagnose where the pain is coming from?

2) regarding the posterior fusion for revision, how much more painful do you think that is for than the Anterior approach? Do you have patients that you see on follow up that say the muscle pain is long-lasting with one level posterior fusions? This is probably my biggest concern.

Thank you so much for your time
Lisa

[Donald Corenman, MD, DC]

#26896

Posterior fusions are generally more painful initially than an anterior fusion but the anterior fusion has a higher incidence of swallowing difficulties. The posterior fusion takes longer to solidify and has poorer fixation (the scores and rods have less ‘bite” or holding power which means that the time requirements for a collar are longer.

Now, a common technique for repairing a failed anterior fusion is a posterior fusion so don’t throw this technique out. If you had a previous block of the pseudo level without relief, this generally points to other pain generators and not the C6 nerve although the block could have been poorly performed making for a false negative (the nerve is compressed but we are misled by the failed block thinking it is not the nerve).

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.

[Author]

Posts