[failedACDF]

#11576

I am very sorry for such a long and detailed email, but I am hoping that you might have some advice for me, and also that my history might help others. Essentially in a nutshell I had ACDF surgery in NYC performed by a top surgeon at a very prominent hospital. I am in need of revision surgery and have received three completely different opinions from my surgeon and two other very prominent surgeons at very prominent NYC hospitals. I have done alot of research and am unable to find the right solution. I have been advised that if I do not perform further surgery soon, my pain and numbness may become permanent. I am a 52 year-old male and had ACDF surgery on 5/12/14, utilizing allograft struts and an Atlantis plate. I do not smoke, wore a hard collar for six weeks post surgery, have normal vitamin D levels and did not take any NSAID’s. Prior to surgery I had very bad pain in the shoulderblade area. When I awoke, my shoulderblade area was burning really bad and I had really bad numbness as well in the scapular region. One month after surgery my right arm became very numb for a two week period. Eight weeks after surgery my right arm became very numb again and has continued through this point. My right arm also feels cold and feels like it is twitching at times. Initially the shoulderblade pain was better post surgery then pre-surgery, but at times has been worse post surgery than pre-surgery. The pain post-surgery has been constant, except for one day two weeks ago and two days last week, when it surprisingly got much better, before flaring up again. The pain and numbness in the right arm are made worse by turning my head to the left or bending my neck. An EMG was done on 9/3/14 with the following finding: “This is an abnormal study, with electrophysiological evidence of a right suprascapular neuropathy with acute and chronic denervation. There is electrophysiological evidence of a chronic right C7 radiculopathy.” An MRI was done on 9/17/14 with the following finding in connection with C5-7 (C3-4 shows severe right foraminal narrowing caused by uncovertebral degenerative joint changes and T2-3 shows a broad-based central disc herniation with paracentral components and bilateral foraminal narrowing): ” At C5-6 there is apparent moderate to severe right and mild to moderate left foraminal narrowing. Right foraminal disc/osteophyte complex and foraminal narrowing appears improved when compared to preoperative study. At C6-7 there is moderate to severe right and moderate left foraminal narrowing. This appears to be relatively similar in appearance to the preoperative exam. Right shoulder radiographs were done on 9/29/14 and show as essentially normal. Cervical radiographs from the same date with AP, lateral neutral, flexion, and extension views show as follows: “Hardware is in appropriate position. No significant listhesis or dynamic instability. Vetebral body heights are maintained. There is mild multilevel arthosis and moderate multilevel uncovertbral hypertrophy is present. Prevertebral soft tissues are unremarkable.” CT scan of 10/6/14 shows: “C3-4 moderate to severe right neural foraminal stenosis. C5-6 mild central canal stenosis. Severe right and moderate left neural foraminal stenosis. C6-7 mild central canal stenosis. Severe right and moderate to severe left neural foraminal stenosis. C7-T1 no stenosis. Moderate right and mild left facet atrophy. There are large anterior osteophytes at both the C5-6, and C6-7 levels, worse at the right on C5-6. There is incorporation of the intervertebral cage at the superior endplate of C6, but only partial incorporation of the inferior endplate of C5. Very small amount of bony bridging is seen at this motion segment. At C6-7, there is incorporation of the intervetebral cage to the inferior endplate of C6, but only partial incorporation to the superior endplate of C7. There is productive bone at the disc space, but no intervertebral body bony bridging. The positioning of the hardware is anatomic.” A second radiologist read the CT scan as showing motion at both the C5-6 and C6-7 levels. The surgeon that performed my operation would like to do a posterior laminotomy and forinatomy on the right side. The second surgeon said that he needs to do a new ACDF and remove the plate and bone grafts and use autografts. He told me that he needs to do it prior to fusion occuring. He is not sure if I will fuse and advised me that fusion typically occurs within three months. He said revision ACDF is much harder to do if fusion occurs. He said that an anterior approach is the only way to remove the large anterior osteophytes. This surgeon is the only one that did a CT scan. He felt that the osteophytes were not visible on the MRI as clearly, and said that the operating surgeon may not have known they were there. He said that a posterior laminotomy and forinatomy would only have a 50% chance of working. Everything I have read suggests that anterior osteophytes need to be removed with an anterior approach. But I have also read that revision anterior surgery is dangerous, has a lesser chance of fusion, and has significant risks of dysphagia and other possible complications. The third surgeon (also very prominent, but with a different hospital) wants to do a posterior laminectomy and forinatomy, with instrumentation and autografts. He would utilize two rods and screws to fuse the back sides. His view is that this is the best approach, since if the front didn’t fuse, in his view it won’t matter, since the back should fuse. While he wouldn’t be able to get the anterior osteophytes, he said that opening up the space in the back is 95% certain to solve the problem. I know that such a posterior approach is very painful and has a long recovery. This leaves me in my present predicament, which is bad pain and numbness in the right sholder blade and arm (shoulder blade improving and arm getting worse, except for the few days when the pain spontaneously greatly improved before returning). I have also seen a physiatrist who tried nerve hydrodissections as well as barbotage treatments, both with only minor improvements. I also did an 8-week course of physical therapy. Thanks very much for any advice.

[Donald Corenman, MD, DC]

#11587

Holy moly- multiple paragraphs would help me for the next response.

First, increased pain after ACDF surgery that is the same pain but more intense should in my opinion have a work-up. Normally, the shoulder and arm pain is improved significantly. There can be new aching between the shoulder blades which is caused by the restoration of disc height (by the stretch of the previously contracted posterior ligaments).

I assume that your level (C5-6 or both C5-6 and C6-7???) did not fuse after surgery which is why you need a revison surgery. There should not be much motion in this area (called a pseudoarthosis) so your complaint of increasing pain with motion could be an indication of a problem at another level.

You still have significant residual compression at the C5-6 level (“At C5-6 there is apparent moderate to severe right and mild to moderate left foraminal narrowing. Right foraminal disc/osteophyte complex and foraminal narrowing appears improved when compared to preoperative study”).

You also have significant compression of the C7 root (“At C6-7 there is moderate to severe right and moderate left foraminal narrowing”).

You have a pseudoarthrosis (lack of fusion) of C5-7 according to your CT scan (“There are large anterior osteophytes at both the C5-6, and C6-7 levels, worse at the right on C5-6. There is incorporation of the intervertebral cage at the superior endplate of C6, but only partial incorporation of the inferior endplate of C5. Very small amount of bony bridging is seen at this motion segment. At C6-7, there is incorporation of the intervetebral cage to the inferior endplate of C6, but only partial incorporation to the superior endplate of C7. There is productive bone at the disc space, but no intervertebral body bony bridging”).

I would agree with the second surgeon. You need to have the plate and cages removed, have a redo decompression of the C5-7 levels and use autograft (your own hip bone) and a plate. In my opinion, this will give the best results by removing the anterior osteophytes and making sure the two levels have the best chance of healing.

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.

[failedACDF]

#11590

Dr. Corenman,

Thanks very much for your reply.

The main reason for the surgeons wanting to do revision surgery is because of the arm and shoulder blade pain and numbness. The regular x-Rays didn’t look problematic, but the CT scan did. Interestingly, only one of the three surgeons utilizes a CT scan before and after surgery, which does seem to be a good practice.

I am 5 months post ACDF and it looks like there is a little bit if fusion. Could I fuse entirely with more time? I note that I don’t have neck pain, which is perhaps a good sign.

How common is revision ACDF surgery done with an anterior approach? I thought it would be dangerous going through scar tissue, etc.? Also, if I don’t fuse the first time, isn’t it more likely that I wouldn’t fuse on a second anterior surgery? The surgeon that wants to redo the surgery with an anterior approach said that it is easier to do it before fusion occurs.

I also wondered if expanding the space from the posterior would allow the nerves more room to be less compressed from the osteophytes, while also through instrumentation in the back increasing the likelihood of a fusion?

So in summary, I wonder if a revision anterior approach is very risky and if it carries a good chance of success?
Thanks

[Donald Corenman, MD, DC]

#11593

The arm and shoulder pain continuance probably is from the incomplete decompression. Regular X-rays are not very helpful for understanding residual compression. A CT or an MRI are the scans to be ordered. The MRI however will not help to indicate fusion while the CT scan sometimes will not reveal continued disc hernation.

A “little bit of fusion” does not sway me one way or the other regarding revision surgery with continued nerve compression. I will assume that there is still significant uncovertebral joint spur compressing the nerve roots (see website under cervical radiculopathy to understand this).

Posterior decompression can work but the success rate is less than a revision surgery from the front. This is because the surgeon can open the foramen with a posterior approach but cannot remove the spur that originates from the front of the neck. This means that the nerve will still be compressed from the front of the foramen but the general “strangulation” of the nerve will be reduced with a posterior decompression.

There is generally not much scar tissue for a revision surgery. I have revised countless cervical spines from the front without any real problem. I am sure that your original surgeon used PEEK cages (small plastic spacers) to create the fusion. These are easy to remove and then the spur compressing the root is immediately behind and to the side of this cage.

See the video on ACDFs on this website to understand the anatomy and technical aspects of this surgery.

Again, the posterior approach is not bad and can be successful but the anterior revision has the best chance of success (at least in my hands).

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.

[failedACDF]

#11597

Thanks again for your advice.

Do you think I would have a problem fusing with a revision anterior surgery if i didn’t fuse the first time?

Conversely, do you think the revision through the anterior becomes harder if I do fuse? The reason I ask is in case I try to give it some more time.

Last question, if I did fuse, I assume that a forinatomy and laminotomy would have essentially no chance of success (based on what I read in your other posts, including the one about Peyton Manning).

[Donald Corenman, MD, DC]

#11598

The reason you did not fuse anteriorly has to do with the technique used. The PEEK cages (I assume were used) are made of plastic and have no biological ability to heal themselves. Only whatever graft is placed into them can heal. This reduces the surface area for healing and makes these cages less effective for fusion.

If you had your own bone used the second time around (called autograft), this increases your chances of healing greatly. The bed has to be meticulously prepared (the old surfaces of the vertebral bodies) by hand milling these surfaces until they are parallel (see the video on ACDF to understand this).

There is a chance that a posterior foraminotomy will work but the chances of success are less than a redo of the anterior surgery. I would say 70% vs 90-95%.

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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