Cervical MRI Result - PT for Severe Foraminal Stenosis?

Tagged: neck nerve root compression and pain/weakness- mountain biking

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Seven7
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January 16, 2020 at 9:31 pm

Post count: 1

#31925

Dr. Corenman,

I found your website while researching my latest MRI results and I’m amazed at the time and effort you take to respond to questions in this forum. I first noticed neck pain between the shoulder blades that would run down my right shoulder blade accompanied by right arm numbness in 2008. I recall my first MRI showing mild stenosis and a round of PT gave me acceptable improvement. Symptoms gradually returned and I completed another round of PT in 2014 which didn’t provide much relief.

Neck and shoulder pain has increased in both frequency and intensity in the last 4-6 months. Neck pain is 60% and right shoulder blade pain is 40%. Also experiencing weakness in the right shoulder and forearm along with a new general feeling of clumsiness in both arms. My GP sent me off for a new MRI and EMG consult. MRI results below and I’m hopeful that another round of PT will provide additional relief? Trying to avoid surgery if possible because I ride and race mountain bikes as a hobby, and have been training hard this off-season and really looking forward to a strong 2020.

General: There is minor rotatory levoconvex scoliosis and straightening of cervical lordosis with slight retrolisthesis of C3 over C4. Vertebral body height is adequately maintained. There is mild height loss to the C5-6 intervertebral disc and little height loss to the C6-7, C7-T1 and T1-2 intervertebral discs.

Bone marrow signal/fracture: No evidence of pathologic marrow infiltration. No evidence of prior fracture.Craniocervical junction: Craniocervical junction is normal.Cord: The visualized cord is within normal limits of signal intensity but is compressed as outlined below.

The paraspinal soft tissues are within normal limits.

C2-C3: Unremarkable.

C3-C4: There is minor pseudo disc bulging and small left paracentral disc protrusion/herniation with minor cord flattening and borderline spinal canal stenosis. There is mild left foraminal stenosis from uncinate hypertrophy and facet arthropathy. The right neural foramen is adequately maintained.

C4-C5: There is subtle disc bulging without sniffing spinal canal or foraminal stenosis.

C5-C6: There is a small right paracentral disc protrusion/herniation with minor cord flattening without spinal canal stenosis. There is moderate to severe right foraminal stenosis from uncinate hypertrophy and facet arthropathy. The left neural foramen is adequately maintained.

C6-C7: There is mild disc bulging without spinal canal stenosis. There is moderate to severe right and mild to moderate left foraminal stenosis from uncinate hypertrophy and facet arthropathy.

C7-T1: There is mild disc bulging narrowing the ventral epidural space without significant spinal canal stenosis. There is severe right foraminal stenosis from uncinate hypertrophy and facet arthropathy and there is mild left foraminal stenosis from uncinate hypertrophy.Sagittal imaging demonstrates mild disc bulging and small central disc protrusion/herniation at T1-2 with mild spinal canal stenosis.

IMPRESSION: Minor dextroconvex scoliosis, nonspecific straightening of cervical lordosis and slight retrolisthesis of C3 over over C4 associated multilevel spondylosis most significantly at C3-4, C5-6 and T1-2.C3-4 level, disc protrusion/herniation with minor cord impingement and borderline spinal canal stenosis.C5-6 level, right-sided disc protrusion/herniation with minor cord impingement.T1-2 level, disc protrusion/herniation with mild spinal canal stenosis.

Multilevel acquired foraminal stenosis most significantly moderate to severe right foraminal stenosis at C5-6 and C6-7.

Donald Corenman, MD, DC
Moderator

January 18, 2020 at 11:38 am

Post count: 8660

#31932

Your complaints are “Neck pain is 60% and right shoulder blade pain is 40%….weakness in the right shoulder and forearm along with a new general feeling of clumsiness in both arms”. You hobby is to “ride and race mountain bikes as a hobby, and have been training hard this off-season”. You obviously want to avoid surgery.

Your MRI report notes “C5-C6…small right paracentral disc protrusion/herniation with minor cord flattening without spinal canal stenosis…moderate to severe right foraminal stenosis…C6-C7… moderate to severe right and mild to moderate left foraminal stenosis from uncinate hypertrophy and facet arthropathy…C7-T1…severe right foraminal stenosis from uncinate hypertrophy and facet arthropathy”.

So your “general feeling of clumsiness in both arms” apparently is not from cord compression due to spinal stenosis so that is a major plus as mountain biking does put your neck at risk. You do have severe right foraminal compression at C5-T1 on the right which would correlate with your neck and arm pain along with the feeling of shoulder and arm weakness. See https://neckandback.com/conditions/radiculopathy-pinched-nerve-in-neck/.

The already congested (narrowed) right foramen become more narrowed with extension (backwards bending). Unfortunately, mountain biking causes neck extension due to the need to bend your torso forward to reach the handlebars. You can modify the stem making it shorter and taller to reduce the need to extend your head but this will make your balance especially for climbing altered.

You could try selective nerve root blocks (SNRB-see https://neckandback.com/treatments/epidural-injections-and-selective-nerve-root-blocks-diagnostic-and-therapeutic-neck/) to reduce the inflammation and pain but these won’t reduce the compression pressure of the nerve roots. There is some risk living with these compressions as if you do have motor weakness from root compression, sometimes even after surgical decompression, the root won’t recover.

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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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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Cervical MRI Result – PT for Severe Foraminal Stenosis?