[icckart]

#9734

I’ll post my questions up front so that readers can decide whether or not to wade through the full details:

Questions:
1) Is cervicogenic neural coupling “real”? In other words, can “cervicogenic” headaches, facial numbness, etc. really be explained by cervical spinal neurological issues (nerve entrapment for example).

2) Has anyone else experienced facial cutaneous lack of or change in sensation (numbness or tingling) that is correlated with cervical spinal issues?

3) Is there really a known nociceptive feedback pathway between the trigeminal nerve (facial innervation) and the cervical spinal nerves? If so, how far down does this coupling extend (C2-C3 or as low as C5-C6). I’ve read the med. literature and this seems to be in dispute. My neurologists (two now) both refuse to believe that cervical spinal neurological issues can cause facial numbness, despite my presenting them peer reviewed articles from multiple medical journals.

4) Can cervical spinal problems (stenosis, foraminal narrowing leading to root compression/entrapment, etc.) also account for lower limb symptoms (i.e. tingling and numbness in the toes, loss of cutaneous sensation)? Again, both neurologists contend that this is not “anatomically” possible!

5) Do any forum members also have Parkinson’s Disease? Has it (in your opinion) in any way contributed to your spinal issues?

Background:
I have early-onset Parkinson’s Disease (I’m 52, male). I don’t believe that is directly related to my spinal issues, but the muscular hypertonicity associated with PD may be a contributing factor. I have been active in several different sports (cycling, mt. biking, go-kart racing, windsurfing, snow-boarding, etc.) most of my life.
I have symptoms that are similar to those described by multiple participants on your forum.

Symptoms:
1) Neck spasms (predominantly trapezius and sternocleidomastoid), which lead to progressive, bilateral numbness and “tingling” sensation, starting with my toes, spreading to my fingers, and eventually resulting in the loss of all cutaneous sensation on the right side of my face. This is often accompanied by a “burning” sensation in my forearms and calves (predominantly right side, sometimes bilaterally).

2) During these acute spasm episodes, which are typically induced by turning my head to the ROM limit on either side (with right ROM much more limited), a “feedback” effect seems to occur. By this I mean that the neck muscles begin to (involuntarily) tighten, leading to increasing numbness with the following progression: right toes, left toes, right finger tips, left finger tips, right cheek, right earlobe). This is coincident with a noticeable displacement of my neck (without head rotation) to the right, predominantly along the axial plane.

3) During onset of one episode (fearing myelopathy or other irreversible neurological damage) I went to the local E.R. There I was given an intra-muscular injection of Diazapam. Within 15 minutes, the muscle hypertonicity began to subside, as did the other symptoms (tingling and numbness).

4) An oral dosage (5mg) of Diazapam also produces the same mitigation of symptoms, but with some delay (typically being effective within 30-45 minutes). I have been prescribed Metaxalone and Cyclobenzaprine (standard adult dosages), but neither is effective when an acute “spasm” occurs. Either may be effective if taken prior to acute onset as a prophylactic. I don’t have enough experience with these drugs (yet) to determine this.

5) I was also prescribed 10mg/350mg of hydrocodone/acetaminophen, but do not have much (if any) pain associated with these symptoms.

I have had the following tests performed:
1) Cervical, Thoracic, and Lumbar spinal MRI imaging without contrast, all in the standard prone position. I have the radiologist’s reports and raw DICOM images for all three. The Thoracic and Lumbar MRI were unremarkable, with no indication of stenosis, myelopathy, or central canal narrowing. The relevant “impression” portion of the Cervical imaging study is:

a) Degenerative disc disease, hypertrophic spondylitic, and mild to moderate
disc bulges changes of the posterior elements scattered throughout the cervical
spine.
b) Moderate C5-6 and C6-7 and mild C4-5 central canal stenosis, based on
disc/osteophyte complexes, with slight indentation of the anterior aspect of the
spinal cord at the C5-6 and C6-7 levels. No evidence of myelopathy.
c) Mild to moderate left and moderate to severe right C5-6 and severe right and
moderate left C6-7 neural foraminal narrowing.

2) MRI of the brain, taken in 2010 to rule out other causes of my tremor (attributed to PD). There were no unusual findings here, per the radiologist’s report.

3) Upper and lower limb EMG/NCV tests. I do not yet have the final report for this, but was told during the testing that some of the latencies were abnormally long. The EMG action potentials and velocities were normal (good CAP and >50 m/s velocities). The abnormal latencies are unilateral (right side only), but present in both upper and lower limbs. Upper limb abnormal onset delays are only evident in the ulnar nerve. In the lower limb only the peroneal nerve appears to be affected.

I have been to two neurologists and a physical medicine M.D. (who performed the EMG/NCV) and have an appointment in 2 weeks with a neurosurgeon. Both neurologists claim to have no explanation for my symptoms. Both claim that neither the cervical stenosis nor spurring is severe enough to account for my symptoms. The T2 cervical MRI images show none of the “telltale” signs of myelopathy (no white spots in the cord itself). Both claim it is simply not anatomically possible for cervical spinal entrapment (or foraminal root compression) to cause the numbness in my toes (which is now chronic)!

The facial numbness perplexes them completely. Based on my own research (I’m not an M.D., but have a Ph.D. in bio-medical engineering), I have found several references in the med. literature documenting cervocogenic headache, and (less commonly) facial numbness resulting from C2-C3 spinal abnormalities. This is based upon a postulated (and disputed) nociceptive neural feedback pathway between the Trigeminal nerve and the cervical nerves, possibly extending as low as C5-C6.

I suspect cervical spinal instability can explain some of these symptoms. During an acute event, the displacement of my neck is quite visible (confirmed by my wife).

Per my physical medicine specialist’s recommendation, I am scheduled for a cervical epidural steroid injection. Clearly there is some (albeit small) level of risk associated with this procedure.

Any comments/suggestions would be greatly appreciated, especially opinions as to whether or not the steroid injection is advisable (i.e. benefits outweigh the risks).

[Donald Corenman, MD, DC]

#9794

Is cervicogenic neural coupling “real”? In other words, can “cervicogenic” headaches, facial numbness, etc. really be explained by cervical spinal neurological issues (nerve entrapment for example).

Facial numbness cannot be explained by cervical spine problems. The facial nerve exits through the skull directly into the face and bypasses the spine. Occipital headaches however can be generated by the neck. The greater and lesser occipital nerves originate from the neck and travel over the head to the top of the eyes and ears.

There are a handful of patients I have who think that facial numbness originate from the neck as they have neck pain associated with facial symptoms but I have not been able to make a neurological connection between these two structures. There is some evidence that there are cranial nerve nuclei (the origin of these nerves) that may descend into the upper cord at C1 or C2. Even if this is true, there is no evidence of cord compression that will affect these nuclei in patients who connect facial numbness to cervical spine issues.

Can cervical spinal problems (stenosis, foraminal narrowing leading to root compression/entrapment, etc.) also account for lower limb symptoms (i.e. tingling and numbness in the toes, loss of cutaneous sensation)? Again, both neurologists contend that this is not “anatomically” possible!

These neurologists may not understand the question as I see this pattern every week. This symptom pattern is produced from myelopathy (see website) and these symptoms are common. When the cord is compressed and malfunctioning, legs can become weak with strange symptoms such as paresthesias (pins and needles), weird cutaneous symptoms (cold water trickling down the leg or bugs crawling on the skin) and numbness.

Parkinson’s disease is a disorder of the substancia nigra within the brain and can cause many weird symptoms. I am by no means an expert on Parkinson’s disease but I do have patients with this disorder. The stiffness and change in gait associated with Parkinson’s disease can abnormally load the spine and magnify any spinal disorder that is not previously symptomatic.

Your MRI report of “Moderate C5-6 and C6-7 and mild C4-5 central canal stenosis, based on disc/osteophyte complexes, with slight indentation of the anterior aspect of the spinal cord at the C5-6 and C6-7 levels. No evidence of myelopathy.
c) Mild to moderate left and moderate to severe right C5-6 and severe right and
moderate left C6-7 neural foraminal narrowing” could be an indication of the beginnings of myelopathy but the radiologist is not too concerned about this compression.

What are the findings of your physical examination? Do you have long tract signs (hyperreflexia, clonus, Hoffman’s sign, imbalance, incoordination)? Do you have the typical symptoms of myelopathy (see website)?

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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