[Deadpool]

#21364

Dr Corenman,

Several years ago I had an anterior fusion at C6-C7 as a result of a disc herniation where the nucleus of the disk came apart and crushed the nerve into my LEFT arm. The pain in my left shoulder and arm was excruciating and I could not use my arm so I had to have the surgery right away. The fusion was one level using a PEEK cage, my own bone material, as well as a plate and screws. After the surgery the pain was much improved, as was my arm use. About the only residual long term issue has been some numbness of the middle and pointer finger on my LEFT hand which the surgeon said could be the result of permanent nerve damage.

One year post-op I had an MRI and CT scan done. The radiologist who read the CT said I was fused. The surgeon read the CT and also said I was fused, although he did raise some concerns in his report as to what he was seeing within the graft. A few months later my residual issues resolved. I went on to lead a very active life both at and outside of work for several years.

Several months ago I tripped and fell backwards at work. I tried to break my fall as I went down by reaching out with my right hand to grab something, but to no avail. When I fell my neck snapped backwards and my right arm was somewhat hyperextended above me. I immediately felt a sharp, stabbing, searing pain into my RIGHT shoulder. Pain was about an 8 out of 10. I ended up seeking medical attention and the doctor said I likely injured my neck.

I ended up seeing an orthopedic surgeon (not the one who did my prior surgery) as I was having neck pain, pain between my shoulder blades that went over into my RIGHT shoulder (mostly the back of the shoulder, but some top and front), slight right arm pain, and numbness into my RIGHT hand, thumb to middle finger. I also had right hand grip strength issues and because of the numbness I sometimes drop things like car keys, a pen, etc (I am right hand dominate). I also have daily headaches. Pain currently varies from a 3 or 4 in the morning to a 6 or 7 with occasional 8 by end of day. The more active I am the worse it seems to be. I did 2.5 months of PT. About all that did for me was to get most of my right hand grip strength back. Numbness is still there in those right three fingers. I am currently working a reduced work schedule with a 25 lb lifting restriction.

In the recent months I have had an MRI and CT scan. Of note the 2015 MRI says:

At C4-C5 there is a broadly based posterior annular tear extending across the full width of the spinal canal, eccentric to the right of the midline. The disc indents and deforms the spinal cord and is accompanied by osteophytes. The disc and osteophytes measure 3-4 mm and have increased significantly since the prior examination in 2009. The spinal cord is ventrally indented and flattened, especially to the right of the midline. The osteophytes extend laterally into the neural foramen and result in moderate right-sided foraminal narrowing, increased in degree since the previous examination. Small uncovertebral osteophytes are noted on the left side. Mild facet joint remodeling is noted bilaterally, representing a subtle change.

At C5-C6 there is marked degeneration of the disc, with sclerosis and irregularity of the endplates. Small uncovertebral osteophytes are noted left side, unchanged since prior study. Foramina appear widely patent and unchanged since prior study.

The fused C6-C7 level appears unremarkable. Dorsal margin of the disc is unremarkable. Foramina are widely patent. Facets appear ununited.

The 2015 CT scan reads partially as follows:

Reconstructed images demonstrate postoperative changes at C6-C7 with plate and cortical screws. Complex transverse radiolucency present within the graft with no evidence of solid fusion. No radiolucency associated with the cortical screws. No vertebral fracture.

C6-C7: No central stenosis or foraminal nerve impingement. Normal facet joints.

C5-C6: Moderate severe disc degeneration with ventral gaseous vacuum phenomenon. Bulge and osteophyte abuts the thecal sac without cord compression. Mild right foraminal narrowing. Normal facet joints.

C4-C5: 3.5 mm central and right median disc herniation abuts the ventral cord and encroaches on the proximal right C5 nerve. The left nerve root canal is patent. Mild right facet joint narrowing.

The orthopedic surgeon I have been seeing looked at the 2009 CT scan and says it is faintly evident on that scan that there was not a fusion one year post-op. He showed me the 2015 CT scan and it is readily evident that there is not a solid fusion and he said in fact it is getting worse.

For pain I am taking 600 mg x 3 a day of Gabapentin, and 20 mg x 1 time a day of Cymbalta. I was taking Flexeril as well as Tylenol #3 for the headaches, but because I have to drive for work I could only take those sparingly.

He has two recommendations. Continue to treat it conservatively and basically live with it best I can. Or, if I can’t live with it then he wants to do a THREE level fusion (C4-C5, C5-C6, C6-C7) and to do it BOTH anterior and posterior. He says it is a long recovery with at minimum 6 weeks no driving and 6 to 12 weeks off work. He also says because it will be a three level fusion, he would issue significant restrictions after the surgery is done. He said he can’t say for sure, but likely he would limit twisting, reaching, bending and repetitive lifting over 20 lbs.

I have several questions you may or may not be able to answer:

What is your impression of the MRI and CT scans?

Why do I often feel better in the morning and worse at the end of the day especially after and active day?

There is marked difference in what the fusion looks like from 2009 to 2015. Is this because it has been wearing or moving causing it to break down?

My surgeon says that over time the screws will likely loosen and the plate could very well break due to micromotion. Do you agree with this?

What is your thought of the recommended THREE level 360 fusion?

What other conservative treatment may help (I have done 2.5 months of PT and my surgeon did not feel that injections would be beneficial)?

What is the success rate of a three level fusion such as this, considering I already have had a failed single level (I don’t have any of the enhanced risks such as being a smoker, diabetes, etc)?

Is the ventrally indented and flattened spinal cord at C4-C5 a big concern?

Can you relate which of my symptoms might be coming from which of the areas that there appear to be issues?

Can you give me and idea of what kind of long-term restrictions you would issue if I decided to treat conservatively and not do the surgery? What would you restrictions likely be if I did the three level 360 fusion?

Thank you!!!

[Donald Corenman, MD, DC]

#21379

First-it is not uncommon for an ACDF fusion with PEEK cages to go on to a lack of fusion. About 1/2 of these pseudoarthoses are stable with a fibers union and create no symptoms. Your comment “I went on to lead a very active life both at and outside of work for several years” indicates that this level was stable for some years.

The accident at work could have been enough force to injure this fibrous union level or could have injured the levels above or below. Arm pain that radiated to your hand would indicate involvement of the C5-6 or C6-7 level as the nerve root at C4-5 only radiates into the shoulder. I would assume that your shoulder has been cleared of instability or a rotator cuff problem as that is in the differential diagnosis.

At C5-6, you have cervical isolated disc resorption which can cause your base of neck and bilateral shoulder pain. According to the radiologist, your foramen (the nerve exit zones) are not compressed so the right arm pain is probably not from this level. You do have foraminal stenosis at C4-5 along with cord compression (the radiologist does not note the degree of canal narrowing or stenosis). I assume you do not have myelopathy-look that up on the website.

I think some diagnostic blocks could be in order. Your neck pain is probably from the C5-6 disc and probably from C4-5 also. Again-make sure the right shoulder does not have pathology.

The C6-7 level might be able to be left alone but this depends upon the findings of X-ray, CT scan and MRI. This is not something I can comment on without image review. You certainly might need an ACDF at C4-6. Based upon your image readings, you probably would not be a candidate for an artificial disc. I almost never perform an anterior and a posterior cervical fusion at the same time as I find no need for it. Fusion rates are quite high for autograft and relatively high for donor bone (allograft)

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.

[Deadpool]

#21459

Dr. Corenman,

Thank you very much for your reply. Since writing this I have went to see another orthopedic specialist who specializes in non-surgical conservative treatment. In a nutshell, he says there is nothing he can do that has not already been done and that my choices are to live with it the best I can (knowing it will likely get worse), or to have the surgery that was recommended.

We went over in-depth the scans from years ago as well as the most recent ones. He, along with two other orthopedic surgeons, all pointed out the obvious cleft running completely through the middle of the C6-C7 “fusion” and all have said it is much more evident now than it was years ago. Also, although I don’t recall his exact technical terms, in a nutshell he said the two levels above the fusion site look real bad.

As for my right shoulder, all have checked it out and none of them have said there is anything wrong specifically with my shoulder. They have all said the pain is likely from my neck.

As for myelopothy, I looked that up on here and about all I can say is that my right hand has some numbness or pins and needles in the thumb to middle fingers, and I occasionally drop things I hold lightly, like car keys or a pen, etc. It appears to me that is a result of sensation changes to my fingers, but maybe there is more to that?

As to the IDR, I found that to be interesting as well especially as it talks about vibration and impact. I drive tens of thousands of miles a year and since my injury last fall driving really makes things worse, as does activity in general (I am working a reduced work schedule since my injury this past fall to try to limit my driving, etc). As I said, my day often starts with my pain in my neck and right shoulder about a 3 to 4. As they day goes by, it increases to about a 6 or 7 with the occasional 8, again mostly neck and right shoulder. The more active I am, the worse it gets by end of day for the most part. And, the worse it gets the worse my right hand symptoms are for the most part. I also have the daily headaches which are often worse the worse my neck and shoulder pain is.

Also, when tipping my head back and/or to the right this increases my neck pain, pain into my right shoulder, and the numbness and pins and needles in those fingers on my right hand.

Thanks again for your help and insight.

[Donald Corenman, MD, DC]

#21466

With the report of a radiolucent line at the previous fusion level (“the obvious cleft running completely through the middle of the C6-C7 “fusion”), this is most likely a non-union that is mobile. Since C5-6 has IDR but no right foraminal stenosis and C4-5 (which does have right foraminal stenosis) cannot cause paresthesias (pins and needles” into the hand, most likely you have motion at the previous C6-7 fusion level and have developed foraminal stenosis at this level.

Myelopathy is much more than “my right hand has some numbness or pins and needles in the thumb to middle fingers, and I occasionally drop things”. I would say the cause of those symptoms is radiculopathy, probably from C6-7.

So the question is what to do now? You cannot have an artificial disc at an IDR level (C5-6) and cannot have one (in my opinion) at a level with stenosis (C4-5). That means you might be looking at a revision of the ACDF at C6-7 and new ACDFs at C4-6.

You can test to see if the arm pain is generated by the C6-7 level by getting a cervical SNRB at that level and keeping a pain diary.

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.

[Deadpool]

#21469

Dr Corenman,

Once again thank you for your response. You have been very helpful, both with your responses as well as your website in general.

[Donald Corenman, MD, DC]

#21479

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.

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