[beth ann]

#9234

Hi Dr
I was hoping you could help me understand the verbage on my new MRI recently done. The present surgeon says all xrays look good and the MRI report as well, however I am still experiencing severe chronic neck pain and shoulder pain. Recent shoulder MRI also shows bone on bone of the AC Joint and a small rotator tear as well, plus recent EMG results show bilateral ulnar tunnel syndrome. However my neck and upper back hurt so bad, that when sitting and even laying down on a pillow the pain is such that it feels like I can hold my head up.
here is the interpretation noted:

the craniocervical junction appears unremarkable, The cord shows normal signal and normal thickness. Postcontrast sequences did not show any abnormal enhancement

At C2-C3, no evidence for canal or forminal compromise. no evidence of cord impingement. No disk protrusion

at C3-C4, uncinate degenerative changes and facet arthritis seen bilaterally. There is moderate forminal encroachment on the right, mile encroachment on the left. Ligamentum flavum hypertrophy noted. Findings remain stable

Fusion is seen from level C4 to T1. Plate and screws are seen fixating anteriorly. Presence of metallic artifact suboptimum however no evidence for recurrant disc herniation at these levels.
No canal stenosis

At T2-T3 facet arthritis is seen. There is mild bilateral forminal encroachment and impingement of exiting nerve.
At T4-T5, there is presence of from a right paramedian disc protrusion with mild cord impingement.

that was the end of the comparison MRI report.
I also had a 2 level lumbar fusion march of 2013 and am still experiencing bilateral buttock pain, right leg, calf and foot pain- hurting to walk on my foot and the lower back pain is actually more intense than prior to surgery. (recent CT showed that all instrumentation is stable)

What does this new MRI tell me, is there a reason still for the constant neck pain and chronic headaches??

I so appreciate your help and time. I think it is great that you can help people understand the medical jargon that is so difficult for us “lay people” to understand, especially when our own surgeons just nod and say “all looks good” and then tells me that I have to just learn a new way to live with the pain. We should not have to live wit the pain.
Thanks
Beth Ann

[Donald Corenman, MD, DC]

#9240

I have a number of questions. Did you have any work-up prior to the surgery to determine the sources of the pain? What were the indications for your surgery and then what was done? It looks to be an ACDF fusion of C4-T1. What grafts were used? How long from the surgery are you?

What were the initial symptoms are how have they changed? Did you have CT scan to determine if the fusion is solid?

Headaches generated from the neck typically are generated from the facets of C2-3 and C3-4. Both of these levels were not involved in the surgery and your report notes facet arthritis of at least C3-4. You might ask your surgeon if he would recommend facet blocks of these two levels. You will need to keep a pain diary and follow it carefully (see website for explanation of that).

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.

[beth ann]

#9245

Thank you for your reply
The testing done prior to surgery was the MRI and the X-Rays. Nothing was done that I recall to determine where specifically the pain was coming from prior to surgery. We had the X-rays and MRI reports which I assumed at the time was sufficient.
The original pre-op diagnosis was stenosis C4-T1, Spondylolisthesis C4-C5 and C7-T1, Denegenrative joint disease C4-T1, Osteoarthritis several levels.

the surgical notes as to the procedure done:
“”A right sided incision was done longitudinally. The platysma was split along its fibers. Anterior cervical approach was done. Prevertebral fascia was identified. Longus cloi muschles were elevated subperiosteally from the bottom half of C4 to the top half of T1. Large anterior osteophytes were identified at each level. Caspar pins were placed in each vertebra and used for distraction. Complete diskectomies were done. All anterior osteophytes were resected and saved for bone. End plates were prepared for arthrodesis using rasps and curettes and Midas bur. Posterior osteophytes were resected posteriorly. Bilateral neural foraminotomies were done as each level from C4 to T1. At this point, C5 colpectomy was done using rongeurs. All bone was saved. Most of the bone was resected in pieces using ronguers. the posterios cortex was thinned out using Midas, and decompression was done from side to side, and bilateral neural foramina at that level.
At this point, a stackable PEEK cage made by Metronic was packed with autograft and placed into the colpectomy space from C4-C6, and a single level PEEK cages were also packed with local bone and placed at C5-C5, C6-C& and C7-T1. I should add that the reduction of spondylolisthesis was done at C4-C5 and C7-T1 using serial distraction of the dick space as well as cervical traction prior to anthrodesis. After all the cages were placed in, additional bone was packed on the sides of the cages after completing decortication was done. Extenzive amount of irrigation prior to positioning of the bone graft was done, over 2 liters.
At this point, intraoperative Flurosccpoic x-ray showed optimal position of the cages. A 7- mm, 4-level, anterior cervical dynamic plate made by Medtronic was also fitted to the anterior cervical curvature and placed from C4 to T1. Each screw was drilled, and a combination of 14-, 15-, 16-, and 17-mm screws were used. A solid contruct was achieved and plate subsequently self locked.””

The surgery was Done April of 2011, and when asked about going to physical therapy, I was told that the surgery was so extensive that he didn’t want me to do PT.

My thinking is that perhaps not having physical therapy may be a contributing factor to my constant neck pain as well.

regarding the recent MRI result I shared with you.
can you tell me
1) what does “presence of metallic artifact suboptimum” mean?
and
2) regarding my thoracic spine that was noted ” At T2-T3 facet arthritis is seen. There is mild bilateral forminal encroachment and impingement of exiting nerve.
At T4-T5, there is presence of from a right paramedian disc protrusion with mild cord impingement.”

do I have anything to be concerned with in this thoracic area??

( I know my entire thoracic area was not observed during the MRI, only by chance did they see the top portion when viewing the cervical area)

The pain was long lasting in my neck/back for over 15 years, I sneezed one day and my neck felt as though a cast iron pan was being pounded on it – my pain level increased to unbearable.

The surgeon never ordered another MRI or CT SCAN post op. He took x-rays at each visit and said he saw the fusion solid and the screws still in place.
I did wear a cervical bone growth stimulator for several months after surgery (10 hours a day)
(as a side note, since my new lumbar surgery this past march, at my 6 week post op apt, he said the x-rays showed “delayed fusion” in my L5-S1 fusion and ordered a lumbar bone growth stim that I am presently wearing for 1/2hr a day – perhaps I heal slower than normal???- quit smoking many months prior to the cervical surgery 2 years ago)

I hope I answered all of your questions.
thanks again for your time and input
BethAnn

[Donald Corenman, MD, DC]

#9246

The surgery you underwent sounds to be typical for the neurosurgery specialty. These specialists use PEEK cages (plastic) as spacers and then bone graft with these cages. The fusion rate using PEEK cages is somewhat lower than the use of your own bone or allograft (donor bone).

With continued pain, I would be worried that one of the levels did not fuse. The gold standard to discover if fusion is solid is a CT scan.

Continued neck pain however can be from more than a pseudoarthrosis (lack of fusion). You have degenerative changes above and below the surgery levels. Depending upon the findings of a careful history and physical examination, you might be a candidate for a workup to determine if the levels above or below are pain generators. This might include selective nerve root blocks, facet blocks or even discograms (see website for explanations).

The statement “”presence of metallic artifact suboptimum” means that the images around the surgery level are obscured from the metallic plate in your neck. Don’t forget that the MRI is magnetic and metal plates can obscure the images. This is another reason why CT scan is preferred in some circumstances.

“regarding my thoracic spine that was noted ” At T2-T3 facet arthritis is seen. There is mild bilateral foraminal encroachment and impingement of exiting nerve. At T4-T5, there is presence of from a right paramedian disc protrusion with mild cord impingement.” This could be a pain generator and the prior discussion about injection diagnosis would hold for these levels.

At six weeks post-operative for your lumbar spine, it is premature in my opinion to say there is a delayed fusion as the bone graft at six weeks is actually being absorbed and tends to look “less robust” or less dense on X-ray. It is the three month X-ray that can be more informative.

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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