[amandabu]

#33058

Hi Dr Corenman,

In 2017, I started having headaches and was diagnosed with occipital neuralgia. I then began having pretty severe muscle spasms in my neck and shoulder. I was treated with muscle relaxers without relief. I was sent to pain management for occipital nerve blocks and trigger point injections. I started having trouble raising my arms and noticed pain in my axillary area and on top of my shoulder on the right side. An X-ray showed DDD. I was unable to have an MRI as I have a Medical device for my bladder. I was sent to physical therapy. PT and dry needling did not help and I progressed to numbness and tingling into my fingers. I had an epidural injection that did not help. I also had an RFA that seemed to have made things worse.I noticed at work that I was having trouble with fine dexterity of my hands. I began dropping ink pens. I was finally sent to a neurosurgeon for an opinion at my pcp advice. I was found to have cervical kyphosis at C5 that appeared to cause cervical cord compression according to a flexion/extension x-ray. A CT myelogram was ordered but I was scheduled for surgery as well. CT myelogram showed cord compression at C5. I had an ACDF surgery on C4-C6 in Sept of 2018 (just 2 weeks after my appointment with the surgeon).
Right after surgery, I was in a lot of pain and I had a right foot drop. My legs were weak and I had to use a walker. The surgeon could not find a cause for this and actually told me to get rid of the walker and start walking. I was readmitted 3 weeks post op for pain control as well. Since then, I have undergone physical therapy totaling about 8 months, epidural injections, pain management, and about 4 opinions. Because I could not get an mri, I had been diagnosed with anything from functional neurological disorder to now progressive cervical myelopathy with pseudoarthrosis. The most recent diagnosis came from the Cleveland clinic. I am 42 years old and in decent health. I am extremely weak if I walk for anything over 15-20 min. I still have weak arms and sharp pain in my shoulder and down my arm. I have trouble picking up small objects. I walk with a cane. I lose my balance at times.
CT myelogram showed pseudoarthrosis, congenital cervical spinal stenosis, and cord compression at C5-C7. 8/31/19
In office X-ray showed a cervical kyphosis on the level below the ACDF. 8/2019.
I underwent a surgery to exchange my medical device to an mri compatible one.
The mri of my neck showed cord compression and foraminal compression at C6-C7. 8/28/20
1. My question is what would you suggest would be the best way to treat my cervical spine? The Cleveland clinic has offered to do a posterior cervical fusion. Another surgeon locally, has offered to do an ACDF on the level below as well as a posterior fusion on C4-C7.
2. Also, I realize that after surgery I will still have symptoms, but what is the likelihood that if I work with PT, I will be able gain strength and mobility back to have a normal life?
3. What is the likelihood that this will keep happening to levels below where I’ve had surgery?

Thank you for your patience, it’s been a long road!

[Donald Corenman, MD, DC]

#33060

I’ve tried to assemble the salient points here.

“I had an ACDF surgery on C4-C6 in Sept of 2018 (just 2 weeks after my appointment with the surgeon). Right after surgery, I was in a lot of pain and I had a right foot drop. My legs were weak and I had to use a walker”.

“The most recent diagnosis came from the Cleveland clinic…’progressive cervical myelopathy with pseudoarthrosis’…still have weak arms and sharp pain in my shoulder and down my arm. I have trouble picking up small objects. I walk with a cane. I lose my balance at times”.

“CT myelogram showed pseudoarthrosis, congenital cervical spinal stenosis, and cord compression at C5-C7…In office X-ray showed a cervical kyphosis on the level below the ACDF”.

“I underwent a surgery to exchange my medical device to an mri compatible one.
The mri of my neck showed cord compression and foraminal compression at C6-C7. 8/28/20”

“The Cleveland clinic has offered to do a posterior cervical fusion. Another surgeon locally, has offered to do an ACDF on the level below as well as a posterior fusion on C4-C7”.

Lots of facts to process. Your first surgery did not go well and you might have had a cord injury if your symptoms advanced right after the surgery as it sounds. I’m glad your new bladder stimulator is MRI comparable as that is very helpful. I hope the new MRI noted no compression at the failed fusion levels of C4-6 but just lack of fusion (pseudoarthrosis).

You now have cord compression at the level below (C6-7) and with advancing myelopathy as you seem to have, you need surgery to address the C6-7 levels with the C4-6 pseudo levels. This can be performed by a posterior fusion at C4-7 with a decompression at C6-7 or a revision of the anterior surgery, adding the C6-7 level to that for a revision of C4-6 and including C6-7. Part of this decision involves how the pseudoarthrosis appears (did the original surgeon use PEEK cages with a plate or allograft?) and how problematic the C6-7 kyphosis looks. Is there cord signal changes at C4-6 and at C6-7?

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.

[amandabu]

#33076

Hi Dr Corenman,

Thank you for your response.

The original ACDF surgery used a cage, I do know an allograft was not used.

Only the flex and Ext x-ray showed the kyphosis. I believe the surgeon at the time was worried about my weakness and whether I would be ok going thru with surgery and recovering. He wanted PT and another opinion. After the CT myelogram I underwent several months of physical therapy. The mri doesn’t mention the kyphosis. Forgive me for my ignorance, but I’m not sure if an mri usually would show that or not. The mri was limited as well due to the current hardware as well as the limited mri procedure they had to use due to the medical device. (Even though it was “mri compatible”). Not sure if I answered your question or not, but as a patient’s perspective, that is what I know.

I’m not sure how to answer your next question about cord signal changes. I have copied and pasted part of the mri and ct myelogram below.

The Cleveland clinic just wants to do the posterior C5-C7 posterior fusion. The dr states that with that the rest of my spine will correct itself?. I am concerned now that I may not be doing enough. I’m trying to get the best option for myself right now. Thank you so much!

This was from my mri:
C3-C4: Artifact is present. Small disc osteophyte formation is present. No significant canal narrowing is present. Foramina are patent.

C4-C5: No significant canal or foraminal narrowing identified.

C5-C6: No significant canal or foraminal narrowing.

C6-C7: Artifact is present. Disc osteophyte formation is noted. On the sagittal imaging of the canal narrowing is present. At least mild cord flattening is noted. Uncovertebral joint hypertrophy is present. Mild to moderate foraminal narrowing is
identified. This is greater on the left side.

C7-T1: Negative

CT Myelogram:

FINDINGS: Congenital spinal stenosis. Reversal of the usual cervical lordosis. The Graf craniovertebral Junction: Negative.

C2-C3: Grade 1 anterior listhesis. Minor facet degenerative change.

C3-C4: Grade 1 anterior listhesis. No cord or nerve root compression.

C4-C6: Postop C5 vertebrectomy. The prevertebral plate and bilateral C4 and bilateral C6 screws are in good position and intact. No hardware fracture or loosening. Anterior interbody cage extends from inferior C4 through superior C6. Lucencies are seen
within the bone graft within the cage on both the sagittal and coronal reformatted images, indicating nonunion. No cord or nerve root compression at C4-C5 and C5-C6.

C6-C7: Degenerative disc disease and spondylosis. Left posterior lateral foraminal disc extrusion. Flattening of the left anterior cord surface. Slight reversal of the cervical lordosis.

C7-T1: Negative.

T1-T2: Negative.

CONCLUSION:
1. Nonunion of the anterior interbody fusion, C4-C6.
2. Left posterior lateral and foraminal disc extrusion, C6-C7.
3. Congenital spinal stenosis.

[Donald Corenman, MD, DC]

#33083

MRIs are performed in the lying down position so gravity is not part of the equation. This is why X-rays, especially flexion/extension views are equally as important.

Your CT report notes; “C4-C6: Postop C5 vertebrectomy. The prevertebral plate and bilateral C4 and bilateral C6 screws are in good position and intact. No hardware fracture or loosening. Anterior interbody cage extends from inferior C4 through superior C6. Lucencies are seen within the bone graft within the cage on both the sagittal and coronal reformatted images, indicating nonunion. No cord or nerve root compression at C4-C5 and C5-C6.

This indicates the surgery (C4-6 with C5 corpectomy) was successful at decompressing the spinal cord and nerve roots but the graft never went on to incorporate and you never achieved a fusion. The C6-7 level needs to be addressed (“C6-C7: Degenerative disc disease and spondylosis. Left posterior lateral foraminal disc extrusion. Flattening of the left anterior cord surface. Slight reversal of the cervical lordosis”) indicating both deformity (kyphosis) as well as cord compression.

Generally, a corpectomy level that did not fuse needs to be addressed with a posterior fusion and since a posterior approach needs to be done at C4-6, the C6-7 level can be included with a decompression and fusion.

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.

[amandabu]

#33091

Thank you so much for
Taking the time to answer my questions.

I plan to do physical therapy again, after I’m cleared by my surgeon of course. With the symptoms going on over the length of time that they have, do you think that I have a positive chance that I will get my full function back to my arms and legs with hard work? I’ve been told that surgery basically stops progression and will relieve the pain some, but there is only a small possibility that I will get some function back if I work at it. I was curious what your opinion is.

Thanks for your patience!

Amanda

[Donald Corenman, MD, DC]

#33096

My discussion with myelopathy always starts with the “party line” that surgery is designed to prevent progression of the cord damage but most of my myelopathy seem to improve greatly after surgery.

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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