[jasiva]

#27494

Hello Dr. Corenman,
First of all thank you for your great service with this forum.
I am a 40 yr old male, healthy, active.
suffering from next, hand pain, and the worst of all — middle finger pain especially when waking up (unable to sleep more than a few hours even with OTC sleep med)

I have been to many doctors and have MRIs.. C6/C7 bulge with C7 nerve root impingement.

Pain has been on and off — Resistance training / working out exacerbated the problem. In hind sight, if I had stopped all weight training (even light) I might have been fine by now.
Past 4 months — continuous pain; NSAIDs do not help; Nerve medication (Gabapintin, Lyrica) did not help much; Tried chiropractor, accupunture, PT…
Past 3 months — Leg pain (left leg) pain started. Started in the foot, now mostly concentrated in the side of the calf (Tibialis) pain; thigh and side of glutes — both back and front (hamstring and quad) and groin and side thigh pain. Wanted to rule out or pin point to lumbar issues and hence took lumbar MRI in addition to recent cervical MRI. Lumbar does not show big issues. Maybe Piriformis or Sac Joint ? This similar pain came once in Dec 2016, but went away after couple of months. Pressing on the neck muscle at times feels like pain radiating to leg (maybe I am reading too much).
Got an Epidural (Transformanial epidural injection) shot last week. No improvement in pain so far

My MRI and Xray images can be found at — https://photos.app.goo.gl/fcDgymuLC3pSyF0E2

My MRI report about C6-C7 says as follows
At C6-C7 level there is almost 3 mm retolisthesis of C6, diffuse posterior protrusion measuring up to 4mm left paracentral slightly displacing the cord without significant compression or myelopathy. The can is narrowed, less than 9MM AP centrally. There is severe left and moderately severe right forminal stenosis.

To check spinal instability, did a flexion , extension xray (yes.. I flexed to the maximum to get a good view)
Xray came out fine, but for the bone spurs at C6/C7

Should I consider surgery at this time ? Should I get some powerful meds (avoided opioids so far) and try another (one last round of ) chiropractor + PT + Accupunture ?

I put a chart for the various surgical options (and included the Epidural shot, which as I said I got one). I want to avoid Fusion, at any cost, if I can.
What are the other options ? I’ve been reading your forums and you had mentioned formaninotomy or artificial disc replacement may not be good ideas for retlosthesis. But given that the xray shows not much retrolesthesis (unlike the MRI that calls it out) and not instability, can I consider endoscopic formaninatomy and discectomy ?

Thanks again

[Donald Corenman, MD, DC]

#27495

You have a classic C7 radiculopathy from left C6-7 foraminal stenosis. This is noted in your symptoms (“next, hand pain, and the worst of all — middle finger pain especially when waking up”). Your MRI notes “The canal is narrowed, less than 9MM AP centrally. There is severe left and moderately severe right formal stenosis” indicating a very narrowed nerve exit hole.

You don’t note what the X-rays reveal for motion of C6-7 (easy to do if you have a reading computer program like PACS) but I would assume there is not too much motion. You don’t note the height of C6-7 which I assume is significantly narrowed.

With a significant retrolisthesis and what I assume is very poor range of motion of this segment, combined with significant stenosis (“The canal is narrowed, less than 9MM AP centrally”), this would add up to a fusion. I do not understand why the fear of an ACDF as it is the most consistently successful cervical surgery you can have and will reduce the chance of injury of this level significantly.

Peyton Manning had two posterior foraminotomies at C6-7 that were unsuccessful. He then had the ADCF which allowed him to win the Super Bowl.

Artificial disc replacements do not work well if the surgical disc level is half the height of a normal level and I don’t implant them in central stenosis (canal narrowing) conditions like you have.

I cannot tell if you need surgery or not as I haven’t examined you. If you have motor weakness (triceps among others), then I would encourage a surgical ACDF.

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.

[jasiva]

#27501

Dr — Thank you for your response..
I followed Peyton Manning’s surgeries closely as a sports fan, when he was going through his surgeries, his move from Colts to Broncos and success after. And as I am chasing for options with similar issues, I’ve read more medical information about Manning’s conditions and procedures.

The reasons I want to go minimally invasive route is exactly the same as what those of Manning — do no more harm required, preserve motion, avoid adjacent disc problems, start with minimally invasive (discectomy with foraminotomy and/or laminatomy) and if years (10-15 or more years?) down the line a fusion is required address it with ACDF.
Unlike Manning, in my case, I would not be throwing a football almost every day in practice and in games, hence will avoid repetitive motion and I am not going to be tackled by 250 pound men !
And in the past 7 years since Manning got his first surgery, endoscopic technologies should have improved and doctors should have gotten more experience doing those procedures. (as a side note, I am surprised that the US is lagging behind Europe and South Korea in minimally invasive spinal procedures, where for lumbar issues percutaenous procedures have become very common and cervical procedures such as anterior discectomy without fusion are routinely done)

My Xray was more or less insignificant. It called out bone spurs in C6/C7 and narrowing of the disc, but other than that everything was clear.

I want to avoid surgery, and if I have to go for the procedure with minimal damage.

I thank you again Doctor.

[Donald Corenman, MD, DC]

#27502

You can have a posterior foraminotomy if you so choose but you have to understand what the disorder is and how any surgery will affect the outcome. You have severe foraminal stenosis which is normally caused by uncovertebral joint hypertrophy secondary to a bone spur. This condition has two problems that are not solved by a foraminotomy.

The spur originates from the front of the disc space. The foraminotomy is performed from the back. The nerve lies in between. You can unroof the nerve hole exit zone by taking off half of the facet (which is what a foraminotomy does). This makes the diameter of the hole larger but does not take away the spur off the front of the nerve exit zone (uncovertebral joint spur). The nerve still has to travel a larger distance to exit as it has to “wind itself around the spur”. This still allows root distortion and is one of the reasons why foraminotomy is not as successful.

The other problem is that the nerve foramen diameter is significantly diminished by the collapse of the disc height. The disc height is one of the main components of the diameter of this exit zone. The foraminotomy does not restore this lost height and is the second reason why the ACDF for a collapsed disc is generally a better procedure.

This is why Peyton Manning failed two posterior foraminotomies and why he eventually had to have an ACDF.

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.

[jasiva]

#27513

Doctor,
Thank you so much for your kind response.
One last question. What is your advice on Artificial Disc Replacement.
While the MRI mentioned almost 3mm retrolisthesis of C6 on C7, Xrays did not show major instability and the radiation tech did not call out retlosthesis (no references to Grade etc.) with the flexion / extension. You might have seen them as well in the pictures I attached here.

Artificial Disc been advised as an option.

The pros are preserves mobility (vs. fusion), can prevent adjacent disc degeneration, can be done at two levels if required (I need only 1 level attentioon now – C6/C7), no bones shaven (vs. endoscopic formanitomy + laminatomy + discectomy)… and if I need to fuse and do an ACDF in the future I have that option to get to at a later time if I have to. And short term success rate seems to be comparable to those of fusion.

Biggest downside is — It is new, only a few years since FDA approval. Not enough statistics on success rates, other longer term complications., doctors may not have enough experience doing this given its newness.
And is an open procedure (vs. minimally invasive).. so I will not be getting any benefits such as outpatient procedure, less blodd loss, quick recovery, less downtime at work that I would get with posterior endcoscopic proecdure.

Thanks again

[Donald Corenman, MD, DC]

#27515

You need to understand that most surgery is minimally invasive. An anterior approach to the neck is standard whether it is a ACDF, artificial disc replacement or simple decompression. You still need to make a transverse incision in the neck, open the platysma muscle and safely develop a plane between the carotid sheath and the esophagus/trachea.

Some surgeons use their eyes only, some use loops (magnifying glasses worn on their head) and some use the microscope.

There are specific indications for artificial disc replacements(ADR). See https://neckandback.com/treatments/artificial-disc-replacement-adr-for-cervical-spine/. This ADR implant will eventually wear out just like hip and knee replacements (they last 10-20 years) but we don;t know how long the ADR will last. The good news is that they are easy to revise (See https://neckandback.com/conditions/failure-of-cervical-artificial-disc-replacements/).

If you have spurs causing root compression, there is “bone shaven” as you have to remove the compressing structures.

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