AuricMemberSeptember 20, 2011 at 7:03 amPost count: 22
Thank you so much for any help that might be offered.
My orthopedic says I need ACDF for C3 to C7 (four fusions). My neurosurgeon says that I only need C5 to C7 done (two fusions). And I’m facing a regrettable time restraint with insurance.
Tomorrow I am getting a third opinion by another neurosurgeon.
I may be experiencing some gradual drop foot on the right side.
There is only transitory neck pain, but right tricep atrophy is visible. I am unable to overhead extend a dumbbell in my right hand of any real weight, whereas my left can handle 25 pounds easily.
Middle three fingers tingle on the right. Diagnosis DDD, bone spurs, the usual suspects.
Dr. Corenman, I understand that the more noticeable loss of motion comes with three or more fusions from C7 up. Beyond that, what are the benefits of a 4 fusion surgery versus a 2 fusion surgery?
Your time and efforts are appreciated, as is this wonderful website.Donald Corenman, MD, DCModeratorSeptember 20, 2011 at 8:10 amPost count: 8436
Let’s break down this fusion decision into its parts. Your complaint is minimal neck pain and right triceps weakness. You have paresthesias into the right middle three fingers. You question a right foot drop.
The right foot drop is highly unlikely to be derived from your neck. You have insignificant neck pain so you would not be getting a fusion for neck pain. It boils down to right triceps weakness and paresthesias into the right middle fingers. This sounds like a right C7 nerve root compression. This is good reason to consider a one level fusion of C6-7 (ACDF- see website). Now, if there is instability or cord compression or even significant root compression of the levels above, there might be reason for extending the fusion up.
I don’t have the films, your history or your physical examination to help with that determination. Generally- you proceed with fusion for correction of nerve compression, cord compression, deformity or instability. I can’t determine what disorders you have other than a C7 radiculopathy by your descriptions. Just remember- smaller is generally better.
Dr. CorenmanAuricMemberSeptember 20, 2011 at 9:46 amPost count: 22
I can only hope to pay forward to other strangers the kindness you have extended to me. I fully understand that you cannot diagnose in this forum, and that the subjective complaints of a patient are insufficient for anything more than a reasoned conjecture.
Perhaps more details will help not only me, but others who must decide not so much IF an ACDF is needed, but to what extent.
There is levator scapula, as well as teres minor pain and right tricep discomfort. This pain ping-pongs, and it expresses itself if I am standing still or sitting, leaning over a keyboard. As I walk or train, it essentially goes away.
An EMG confirmed the tricep atrophy and the weakness in the teres. It has also been directly observed by three physicians (visually).
Here is an MRI summary.
C2-3. No central or neural foramen stenosis.
C3-4. Posterior disk osteophyte complex eccentric to left and uncovertebral joint hypertrophic changes cause moderate central canal stenosis with the effacement of the ventral CSF space and moderate bilateral neural foramen stenosis.
C4-5. Posterior disk osteophyte complex eccentric to left and uncovertebral joint hypertrophic changes cause moderate central canal and severe left and moderate right neural foramen stenosis.
C5-6 Moderate posterior disk osteophyte complex and uncovertebral joint hypertrophic changes cause moderate central canal and severe bilateral neural foramen stenosis.
C6-7. Moderate eccentric posterior disk osteophyte complex to the right and uncovertebral joint hypertrophic changes cause moderate central canal stenosis and severe right neural foramen stenosis and moderate left neural foramen stenosis.
C7-T1. No significant central canal or neural foramen stenosis.
Impression: Moderate to severe multilevel degenerative disk disease worst at C6-C7, as detailed above.
My ortho (4-fusion suggestion) is the director of spine surgery at a large metropolitan hospital, and has developed some of the hardware used in a fusion. He has been doing this for decades. (That proves nothing, I know. Just putting it out there.)
The neuro (2-fusion) was a director of another large metro hospital for ten years.
If any of the above is helpful, I welcome your elaboration. i will be getting the third opinion tomorrow, and I hope to post it.
Thanks again, Doctor.Donald Corenman, MD, DCModeratorSeptember 20, 2011 at 2:13 pmPost count: 8436
Pain in the teres minor and levator scapulae muscles is most commonly referral point from facets, discs or from nerve irritation. The EMG which confirms triceps denervation indicates a C7 nerve compression. The teres minor weakness is unusual by itself as this muscle is innervated by the axillary nerve from C5 and/or C6. This might indicate the higher nerve roots being compressed but you should also notice weakness in wrist extension and biceps if C6 was involved and deltoid weakness if C5 were involved (holding your shoulder up against resistance).
The MRI reading is appreciated but remember that modifiers are in the eye of the beholder. “Moderate canal stenosis” to one radiologist might be “severe” or even “mild” to another.
Let’s talk about central stenosis. If the cord is compressed significantly, you do have a somewhat greater chance of central cord syndrome with an injury (see website for that description). This injury occurs when you fall and hyperextend your head (impact to the forehead forcing your head backwards). If you do not participate in activities that put you at risk for neck extension (snow skiing, mountain biking, water skiing, horseback riding, contact sports, etc…) then the stenosis is not that important for injury risk.
If however you do participate in sports that put your neck at risk, the danger of injury has to be factored into the need for surgery to remove the stenosis.
Your arm pain and weakness is from foraminal stenosis causing compression of the various nerve roots. Unfortunately, you have multiple levels of foraminal stenosis and at least C5-6 and C6-7 seem to be symptomatic.
So- to a conclusion without a history or physical examination (a far leap of faith), if you had the C5-7 levels fixed, you would be left with C3-4 central stenosis and C4-5 central and foraminal stenosis. You might be able to consider an artificial disc for one level (much depends upon exam and x-rays) or even a combination procedure involving and ACDF, an artificial disc and even a possible posterior decompression (laminectomy, laminoplasty or foraminotomy). Your X-rays including flexion and extension will help. Much depends upon your activity level, your expectations and your physical examination along with personal review of your MRI images.
Dr. CorenmanAuricMemberSeptember 21, 2011 at 10:27 amPost count: 22
Though you have limited access to the test results, your diagnosis is not only appreciated but affirming of the feedback I received today.
The second neuro-surgeon’s opinion came in more conservatively than either of the first two doctors. He said that this is a C7 radiculopathy and needed ACDF on only one segment (C6 – C7). He acknowledged that bone spurs and stenoses were evident elsewhere, but he saw no need for further surgery beyond the one fusion point, considering the limits of my symptoms.
His assessment of what the MRI termed “severe” was moderate. Adjectives are subjective, as you cautioned above. He added that the space between my other C vertebrae was fine, and that I was in no unusual danger of injury. I asked him about my present neck ROM, and he said that too was fine.
The trade-off of so much ROM for my limited symptoms was not worth it at this time. I am going with the one-level fusion.
The initial surgeon characterized himself “as conservative as they come.” And yet, of two other diagnoses conducted with all results and office visits, and two more with only anecdotal or limited access (including yours), all four prescribed more conservatively, from one half to one quarter of the work the original doctor recommended.
Wrist extension and bicep strength are sound. I alternate curl fifty pound dumbbells for eight reps with good form. I will see what becomes of the teres minor issue.
I don’t participate in any sports. I only weight train. I’m soon to be fifty-five, and the gym is a place of refuge. I appear athletic, but I am not very coordinated, agile, or competitive. I only lift.
My bench press has never been strong as a long-limbed individual. But I noted a precipitous drop from 225 to 165 for reps. Overhead military press remains compromised. That lack of strength would come and go in seasons. Now it’s all making sense with this C7 thing. I imagine it was alternately flaring and quieting over the years, and other muscles were compensating whenever possible.
I have pillaged the internet’s ACDF resources, and there are many good sites out there, but this website is a gem among them. Your personal responses have been helpful and alarmingly prompt.
I may start other threads if more questions occur, to keep the forum coherent and searchable. Cheers and thanks to you.Donald Corenman, MD, DCModeratorSeptember 22, 2011 at 12:21 amPost count: 8436
By your description, your C6 nerve root is functioning properly (biceps curls are equal right to left). It appears that you do not put your neck in jeopardy so the stenosis does not post a significant risk, especially if the stenosis is moderate and not severe.
A one level ACDF should decompress the C7 root and give the best chance of arm pain relief and motor strength return. It sound like you are on the right track.
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