[Rich Taylo]

#24150

Dr. Corenman:

My wife is in too much pain, so I am acting as the typist here. About four years ago she had an emergency fusion C2 – C4. That went very well, but about two years later, pain returned a bit lower and a C6 – C7 fusion was done. Coming out of that surgery there were big problems with the region between the two fusions (collapse onto nerve roots?) so a full fusion from C2 – T2 was done. The pain was not resolved and a subsequent revision and removal of one screw was no help. While the structure of the fusion appears solid, we would like to be done with surgery. Our pain management anesthesiologist could not do ablation since the fusion hardware blocked access of the tip from the rear.

What alternatives and what kinds of expertise should we be looking for? I had imagined that ablation from the front by a surgeon, spinal cord stimulation and intrathecal pain pump (though I’ve been told that this in not often used for cervical issues). Pain is most intense in the neck area but radiates to the arms, particularly to the right side.

We are pretty desperate here and I appreciate any guidance you might provide. Thank you

[Donald Corenman, MD, DC]

#24184

It sounds like your wife had a posterior fusion as the only way to perform an ablation is to have access to the posterior neck which would be “blocked” by posterior fusion hardware. What surgeries exactly did your wife have and in what order?

How do you know that she has a solid fusion? Was there a “fine cut” CT scan performed and does it note solid fusion? Is there any continued foraminal stenosis to cause arm pain? Are there hardware placement problems. Why was the previous screw removed?

Spinal cord stimulators can be effective under the right circumstances and with the appropriate technique. I would place the effectiveness at about 50-70%.

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.

[Rich Taylo]

#24214

Thanks so much for your rapid feedback. We went over a substantial file and got the answer to your questions. I’d certainly appreciate your further comments on her condition and next steps. Sorry for the length, but I wanted to be comprehensive.

In reply, my wife answered your specific questions.
“It sounds like your wife had a posterior fusion as the only way to perform an ablation is to have access to the posterior neck which would be “blocked” by posterior fusion hardware.”
After consulting with her neurosurgeon on 10/20/2016, he was frustrated with her continued complaints of pain and believed her #1 issue of urgency was a herniation at L4-L5 that would require a surgical fusion. Unfortunately, she became to upset in his office and at that point he directed her to seek a second opinion.
On November 22, 2016, she was seen for a second opinion regarding lumbar surgery and pain management.
As the previous L4-L5 herniation healed, she was referred to an Interventional Pain Management physician and seen on 12/16/2016.
On 12/22/2016, she received a bilateral facet joint injection to decrease the fluid & inflammation at L4-L5.
1 month post injection, she feels an 75% reduction in lower back pain.
On 1/12/2017, the Interventional Pain Management physician did a diagnostic right medial nerve branch block at the C4 level.
On 1/18/2017, the Interventional Pain Management physician explained that the nerve damage is beyond his skill level.
He felt a nerve ablation at only C4 would give her little relief as the nerve damage is extensive.
He directed her to seek treatment by a neurosurgeon for a complete evaluation as to the extent of nerve damage and possible interventional therapies. Including neuro-stimulator device, intrathecal pain pump or surgical intervention as warranted.
She’s been told narcotic medications are of little value in managing her pain. She steadily tapered from a morphine equivalent of 75 mg. to 45 mg. to 30 mg. to 20 mg. and at this time discontinued all narcotic medication.
She’s experiencing debilitating pain and profound depression related to her lack of physical mobility. Formerly a physically active career woman, she’s lost both strength & stamina. Prolonged inactivity has caused weight gain despite minimal caloric intake.

What surgeries exactly did your wife have and in what order?
2/22/2013: ACDF approach fusion from C2-C4.
7/7/2014: ACDF approach fusion from C6-C7.
Resulting in severe C6 nerve root compression.
1/9/2015: ACDF approach fusion from C2-T2 to relieve pressure on C6 nerve root.
5/17/2016: Posterior revision removed Spinous Process at C7, removed screw at C5 and adjoining rod was cut.

How do you know that she has a solid fusion?
The neurosurgeon explained that the fusion is solid verified per serial imaging.

Was there a “fine cut” CT scan performed and does it note solid fusion?
On 2/18/2016, she had a myelogram with a CT of the cervical spine.
Noted: Old ununited fracture of the T2 spinous process.
Degenerative changes at C1 level.

Is there any continued foraminal stenosis to cause arm pain?
11/08/2016, CT Scan reconstructed per axial, coronal & sagittal plains.
C1-C2: Narrowing at the articulation of the anterior arch of C1 & the dens with bony sclerosis.
C2-C3: No canal or foraminal stenosis.
C3-C4:
C3: Interval removal of a horizontal stabilization rod.
No right posterior rod seen spanning C3-C4 levels.
Mild right foraminal narrowing.
No central stenosis.
C4-C5:
Interval removal of of right pedicle screw.
Minimal right foraminal narrowing.
C5-C6:
No significant foraminal narrowing or central stenosis.
C6-C7:
No foraminal narrowing or central stenosis.
C7-T1:
No foraminal narrowing or central stenosis.
T1-T2:
No foraminal narrowing or central stenosis.
T2-T3:
No foraminal or canal stenosis.
T3-T4:
Mild disc space narrowing with no foraminal or canal stenosis.
T4-T4:
Mild disc space narrowing with no foraminal or canal stenosis.

Are there hardware placement problems?
C4-C5: Right lateral mass screw partially enters the superior aspect of the right neural foramen & approaches the posterior aspect of the right transverse foramen.
*Removed during revision on 5/17/2016.
Unchanged Minimal Lucency around the barrels of the T2 transpedicular screws which may reflect hardware loosening.

Why was the previous screw removed?
After one year of intensive physical rehabilitation, she c/o constant pain radiating down her R arm and between her shoulder blades.
Previous imaging noted a screw at C5 penetrating a titanium bracket and on physical exam, she identified a vertebrae at C7 to her doctor. Explaining the pain was most acute at that level.
Post-revision was remarkable for a seromas developing underneath the surgical incision. At the time of discharge, serosanguinous fluid was leaking from several areas of the incision. 10 days post-revision, bright red active bleeding was observed, she was seen by a neurosurgery resident treated with Keflex and steri-strips applied to the open incision site. Due to a sensitivity to adhesives, her incision became red and blistered. We followed up at a Wound Clinic. After 26 weeks, the incision healed.
She felt pain relief for approximately 6 weeks post-op. After 6 weeks, pain medication was discontinued and the high doses of corticosteroids were out of her system. It’s her belief that the corticosteroids were most effective in controlling post-op pain.
In August, she met a pain management physician who prescribed 40 mg. of Percocet daily which was ineffective. He felt she needed to return to the neurosurgeon and seek alternative pain treatment. See Above.

[Donald Corenman, MD, DC]

#24215

I am somewhat confused as you are adding lumbar to cervical disorders. It is always valuable to keep the neck and lower back separate as not to confuse these two different areas.

She had an initial ACDF from C2-4. She then had an ACDF at C6-7. I am unclear why this C6-7 fusion caused “severe C6 nerve root compression” as the C6 nerve exits between C5-6, one level above the C6-7 fusion. You then note an “ACDF approach fusion from C2-T2 to relieve pressure on C6 nerve root” which must be incorrect. Do you mean a C5-6 ACDF?

This sentence makes no sense “Posterior revision removed Spinous Process at C7, removed screw at C5 and adjoining rod was cut” as there would not be a posterior screw to remove without a posterior fusion which you have not reported 9unless you meant the C2-T2 fusion was a posterior fusion.

Let me know how to understand your report.

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.

[Rich Taylo]

#24238

Dr. Corenman:

Thanks again. My wife and I went through our extensive array of records and have, I hope compiled the relevant comments. Here goes:

After the initial C2-C4 spinal fusion, the radiology report on 2/22/2013 noted: Slight kyphotic deformity at C4-C5 and advanced disc space loss at C5-C6 with endplate hypertrophic spondylosis.

On 6/13/2013, the radiology report noted: Persistent kyphotic deformity below C2-C4 fusion at C4-C5 with mild to moderate disc space loss. At C5-C6, severe disc space loss & hypertrophic endplate spondylosis.
Note: For the following year, my wife had aches & pains believing these were part of normal healing. She was unaware that there were physical problems below the initial fusion. In late May, 2014 she contact the surgeon’s office c/o persistent pain & unexplained fatigue.

On 6/10/2014, the radiology report noted: C5-C6 minimal retrolisthesis & minimal central stenosis with moderate left & right foraminal narrowing. At C6-C7 right paracentral disc extrusion, resulting in canal narrowing measuring 8 mm in flexion & neutral and 6 mm in extension. Mild cord compression is seen in neck extension.

On 6/10/2014, an EMG noted: Left C6 and Right C7 chronic radiculopathies. The high frequency discharges are seen in long term aggravation of the nerve roots. No evidence of peripheral neuropathy or carpal tunnel seen.
She was told that her disc at C6 burst and she needed a cervical fusion at C6-C7. She agreed to the procedure at their outpatient center to be done on 7/7/2014. We had not read or been made aware of any of the above radiology or EMG findings before surgery.

After surgery on 7/7/2014, she complained of severe pain not consistent with normal postoperative recovery.
Radiology: Cervical kyphosis below the C2-C4 segment and above C6-C7 segment with bilateral foraminal stenosis at C6.
Surgical procedure 1/9/2015: Corpectomy at C5 with extension and hopeful reduction of her kyphosis posteriorly. Requiring posterior stabilization with the placement of facet and pedicle screws at the C5-C6-C7 levels connecting them into the existing C2-C4 construct. Posterior decompression to to reduce slip. Plate removed at C6-C7 and lower plate at C4 to place Corpectomy plate anteriorly.

11/9/2015: Radiology report. Patient is severely osteopenic. C5 vertebral body is not identifiable. Unclear if it was severely osteopenic and reabsorbed or was resected with bone graft at this site.
12/14/2015: Right pedicle screw at extends into the right neural foramen at C4-C5 and into the into the posterior margin of the transverse foramen causing mild foraminal narrowing. Lucency surrounding the T2 screws related to loosening has increased from prior study.

Again, patient was unaware of any physical changes and the surgeon scheduled a follow-up in one year.
5/17/2016: Removal of C5 Lateral Mass Screw and cross connector. Partial resection of C6 & C7 spinous processes.
She felt some relief of discomfort and pain until 6 weeks post-op. In addition to an incision dehiscence that required 2 visits to a wound clinic and 6 months to heal, she’s in debilitating pain. During her last visit on 10/20/2016, the surgeon implied that if she had cancer at least their would be an endpoint to her suffering. After suggesting another surgery, we felt it was imperative to look for treatment to decrease her pain and increase her functioning.

I appreciate your input.

[Rich Taylo]

#24239

Additional symptoms
She has bilateral Babinski sign
Also has Hoffmann on right fingers

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