[failedACDF]

#19070

Hi Dr. Corenman,

I just wanted to update you on my situation. As you may recall, I had ACDF C5-C7 done last May, followed by a posterior laminoforamintoomy with instrumentation on the right done this past December. After my most recent surgery, my symptoms were all better for a month, only to come back. What came back first was bad shoulderblade pain and numbness on the right, followed by right arm numbness. I had both an MRI and a CT which showed clear improvement post second surgery. I also tried various pain medicine shots (subcutaneous perineural shots offered some relief).

Currently the arm numbness has improved some in that it is not numb all of the time. The shoulderblade pain and numbness are still pretty bad. I had a Myelogram last week and the pertinent part is as follows:

Interbody fusions with cortical bone graft at C5-C6 and C6-C7 with small areas of bridging across the vetebral bodies. Right lateral fusion with instrumentation from C5 to C6 without hardware complication. The fusion does not appear to be united. Right laminotomy is at C5-C7.

C3-C4 Uncovertebral osteophyte formation compressing thecal sac and right C4 nerve root. Moderate right foraminal stenosis.

C5-6 United interbody fusion. The interbody graft is incorporated superiorly and inferiorly with a transverse defect present. There is bridging bone across the vetebral bodies anteriorly. Right posterior lateral fusion not united. Mild posterior ridging. Prominent osteophyte formation at the uncovertebral joints bilaterally. Mild canal stenosis. Compression of the right auxillary sleeve. Severe right and moderate left foraminal stenosis.

C6-7 United interbody fusion. Right posterior lateral fusion is not united. The interbody graft is incorporated superiorly and inferiorly with a transverse defect in the midportion. Small areas of bridging of the graft across the vetebral bodies. Facet joints are not fused. Mild canal stenosis. Compression of the right axillary sleeve. Severe bilateral foraminal stenosis.

The CT Myelogram shows worse results than the regular CT and MRI showed after my second surgery as well as before both of my surgeries. So I’m baffled as to how I could still have severe narrowing after two surgeries. I also don’t know if my posterior instrumentation would make a possible revision ACDF possible without removing the posterior instrumentation. I also wonder if any of my arm/shoulderblade pain and numbness could be coming from the C3-C4 as well. I certainly am not looking forward to a potential third surgery in a year, but also don’t know if I risk damage by waiting.

As always, I’d very much welcome your views. Thanks.

[Donald Corenman, MD, DC]

#19236

The radiologist report is somewhat confusing. He or she reports “the interbody graft is incorporated superiorly and inferiorly with a transverse defect present” I am unclear if this is a defect in the graft with no fusion in the center or the graft fully intact but not incorporated in the center yet (two very different conclusions).

Having continued “Severe bilateral foraminal stenosis” after an anterior and then a posterior cervical decompression surgery does not make sense. Either the MRI or CT is overestimating the compression, the radiologist has misconstrued the images or the surgery did not do what it was supposed to do.

You mention “C3-C4 Uncovertebral osteophyte formation compressing thecal sac and right C4 nerve root. Moderate right foraminal stenosis” but nothing about C4-5. C3-4 can cause side of the neck pain but generality not shoulder top pain. The C5 nerve (C4-5 level) can cause shoulder pain but not pain down below the elbow.

“What came back first was bad shoulder blade pain and numbness on the right, followed by right arm numbness” could be associated with the remaining continued nerve compression at C6 or C7. The way to prove this is with a highly selective nerve root block (SNRB-see website). If positive (see pain diary), you might be a candidate for an osteotomy of that particular level (another ACDF from the front) and redo decompression.

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]

#19238

Thanks. I think that the graft is fully intact, but without full fusion in the center. The C4-5 shows as mild disc bulging and minimal osteophyte formation on the left uncovertebral joint with no canal or foraminal stenosis and normal facet joints.

I never had a myelogram before, but the myelogram with CT clearly shows much worse than an MRI or regular CT of around the same time frame. The Myelogram with CT was read by a couple of radiologists as well as the surgeon and they all said that it showed severe bilateral foraminal stenosis at C6-7, and severe right at C5-6.

Since C3-4 showed moderate to severe compression, the surgeon wanted to do a selective nerve root block at that level to rule out that playing a part in my problems–he doubted that such level was playing a role, and thought it had to be C5-7. This surgeon is not the surgeon that did my two surgeries. I am extremely baffled as to how I could still have severe compression after two surgeries by a top surgeon. Have you ever seen this before?

Thanks

[Donald Corenman, MD, DC]

#19239

Unfortunately, I have seen this before, especially in a university program with residents and fellows. However, I have not seen continued foraminal stenosis with both an anterior and a separate posterior approach.

Please keep us informed of your progress.

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]

#19531

Hi Dr. Corenman,

I just wanted to gove you an update on my situation. As you may recall, I had ACDF C5-7 surgery last May, followed by a C5-7 posterior laminoforaminotomy with right-sided instrumentation last December.

My recent myelogram shows severe bilateral foraminal compression at C5-7 and my chief complaint is really bad right-sided shoulderblade/scapular pain. The surgeon wants to redo the anterior surgery and also do posterior fusion–a circumferential approach at C5-7.

The surgeon wanted me to do a SNRB at C3-4, due to the myelogram showing severe right sided C3-4 foraminal compression. The SNRB was done with an anesthetic and a steriod. After the SNRB my shoulderblade, arm, and neck pain were 50% better for 3 days, and now are back to the bad level they were at before. Based on the SNRB working for 3 days, the surgeon wants to do a circumferential surgery at C3-C7 (my C4-5 are fine).

I am nervous about such extensive surgery. Based on what I have read the C3-4 does not cause scapular pain, but yet the SNRB there made the pain and numbness 50% better for 3 days. At this point having had two spine surgeries in the last year, I don’t want to go through another without a high degree of certainty that it will work. I also want to make sure that any area that is causing the pain is fixed. What would you recommend? Thanks.

[Donald Corenman, MD, DC]

#19541

I am confused as to why you still have such severe foraminal stenosis after a front and back surgery at C5-7. I guess it is what it is and you still need attention there.

A question. Do you have a solid fusion at C5-7 either anteriorly or posteriorly or both? If you have a solid posterior fusion, you should have a solid anterior fusion also. This would allow a partial osteotomy of only the right side that would obviate the need to do a circumferential redo fusion.

I am apprehensive that the C3-4 level is truly causing shoulder blade and scapular pain. The C4 nerve typically does not radiate to the lower shoulder but can radiate to the anterior chest wall. It may be that the injectionist used a high volume of fluid and this migrated lower to the C5-6 level. It would not hurt to get a highly specific C5-6 and C6-7 block to see how much relief you gain from this intervention. This is true especially if the C4-5 level is planned to be included within the surgery to leave you with a four level fusion.

The diagnostic window for the injection is not three days but three hours only. This is important to understand. Both steroid and an anesthetic (lidocaine or marcaine) are injected. Pain relief twelve hours later is not diagnostic as this is the steroid talking. I could give you an injection of steroid in your knee and your neck would feel better within 24 hours.

The true diagnosis is made in only the first two to three hours as this is when the numbing agent is active. If you had no relief in this period of time, this means the structures numbed are not causing your pain.

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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