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Dear Dr. Corenman,
I was so grateful to find your site. I had ACDF C5-6 in May, 2003, and C6-7 in May, 2007. Four weeks ago I felt familiar pain in my neck, into my upper arm and forearm mainly on the right side. I also have some hand pain and weakness on the right. I would have returned to the neurosurgeon who did the original procedures but I’ve since moved 2000 miles away.
It has been very tough as the pain interferes with my sleep and daily activities. I had an MRI and an initial consult with a neurosurgeon here. He didn’t think the MRI result lined up with my symptoms. What concerned me is on MRI he (and the reading radiologist) only noted one fusion, at C6-7. He said it was possible I had a failed fusion, and ordered a CT and flexion extension X-Ray, which I will have after the first of the year, then return to him.
MRI report says:
Previous intracervical fusion hardware is observed at the C6-7 level with associated susceptibility artifact.
Cervical alignment is normal. No acute fractures identified. No listhesis is seen.
The image posterior fossa and cervicomedullary junction are normal. The cervical cord is normal in signal. No cord compression or cord edema/hemorrhage is identified. No intrinsic lesion is seen.
No epidural fluid collection is observed.
C2-3: unremarkable.
C3-4: minimal broad based disc osteophyte complex effacing the ventral thecal sac. No significant spinal or neural foraminal narrowing.
C4-5: disc height loss. Broad-based disc osteophyte complex effacing the ventral thecal sac and flattening the cord. Mild central spinal stenosis. Moderate right and mild left neuroforaminal narrowing. Possible exiting right C5 nerve root involvement.
C5-6: small broad based disc osteophyte complex with a loss of disc space. No focal disc herniation. No significant central spinal or neuroforaminal narrowing.
C6-7: fusion at this level. No disc herniation or central spinal/neuroforaminal stenosis suspected.
C7-T1: unremarkable.
Impression: anterior cervical spine fusion noted at C6-7 with metallic susceptibility artifact.
No acute fracture or listhesis. No cord compression. No cord edema/hemorrhage.
Cervical spondylosis most significant at C4-5 with right greater than left neuroforaminal narrowing and possible exiting right C5 nerve root involvement. Correlate with patient’s clinical exam.
Ok, so my question, is it even possible to have a failed fusion this far out? The first was done with an autograft, the second with allograft if that makes a difference. I was also under the impression that C5-6-7 were supposed to be all fused together so I’m puzzled and worried. I have a young child to care for and every time I get a tug on my arm a wave of fresh pain hits. I’m miserable and neither ibuprofen nor naproxen have touched it.
Thank you for taking the time to read this…I eagerly await your opinion.
Depending upon the nerve root involved, weakness should be in a specific set of muscles. Since the pain radiates to your hand, I can rule out the C5 nerve (C4-5 level). Do you have biceps, triceps or hand weakness? Where do you have pain in your hand? The thumb side or the pinky side? Is the pain on the palm side or the dorsum (opposite side) of the hand?
I would assume by the readings of the MRI and X-rays that the prior C5-6 fusion level had an autograft that “melted away- very uncommon” or the surgeon used no graft at all. Using no graft was a technique that some neurosurgeons used in the 1990s and which probably continued to be used until about 10 years ago. The reading “C5-6: small broad based disc osteophyte complex with a loss of disc space” could be consistent with that technique.
Could it have been that the original surgery was at C6-7 and the subsequent surgery was to correct a pseudoarthrosis (failed fusion) at the same level?
The radiating pain does sound like radiculopathy (nerve compression) but also could be referral from the shoulder (rotator cuff or other pathology). Identification of the pain source is performed by a thorough history and physical examination, careful review of the images and possible nerve blocks (SNRB-see website).
You need a spine surgeon who can take the time to diagnose you and prescribe or perform the correct procedure, be it injection, PT or surgery.
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.Thank you so much for replying to me!!! I very much appreciate it. I know the first one was done with an autograft…I have the dent in my hip to prove it. :) That’s another reason I find it so bizarre!
After reading your very informative response along with parts of your site, I’m starting to think I did a poor job explaining my pain to the neurosurgeon. I admit that I have been pretty upset about this, and with the lack of sleep and pain I’m not really “myself”. I guess there’s not a whole lot I can do until I have the Xray and CT and return to him in January.
I’m way out of my element. When the first incident happened, I had a dozen referrals to the surgeon I went to. I did everything he told me to do and beyond (from acupuncture to PT to pain management) and did end up having the surgery. He told me that there were “protein strands” irritating the nerves, describing the disc as “shredded” (at the C5-6 level). The second time, I actually had thought I’d hurt my shoulder. I went directly to PT, and it was there that it was determined it was not my shoulder at all, but my neck. Back to the neurosurgeon and before I could blink, I was having the second level fused. The recovery from that one was easier because of the allograft.
I’ve been trying to get the records from the first two procedures so at least we have something to go by. I’m having zero luck with that, unfortunately (keep leaving messages at the practice, keep getting no call back…I’m sending in a written request today and hoping for the best).
The hand pain comes in little “zaps” to the thumb side of the hand, palm side. The forearm pain and tricep-area pain also comes in zaps. (By “zaps” I mean it’s not constant, and when it comes it feels, well, “zappy”.) It is not an unbroken “line” of pain. I feel it in my neck primarily (and I do mean primarily…it is constant there, but has zaps or “waves” of more intensity).
I wonder if this is all in my head. :(
Are these electrical “zaps” associated with neck motion or shoulder motion? You can check this simply. Keep your neck flexed and still (close to your chin) and move your shoulder overhead back and forth. Then keep your shoulder still and extend your neck (look upwards) while moving your head side to side.
Generally, if you have nerve compression originating from your neck, you will have these “zaps” when your neck is back but your shoulder is down. If you have thoracic outlet syndrome (see website), these zaps will be generated by moving your shoulder upwards with your neck flexed. This is not an absolute differential test but a good first step to understand your disorder.
If your previous surgeon will not answer your records request, you can contact the hospital where the surgery was performed. They will have the operative report and can give you a copy.
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.Oh thank you! I don’t know why I didn’t think to call the hospital; I’ll be doing that today. And thank you for the shoulder/neck information. It’s definitely not the shoulder/thoracic outlet syndrome by those two indicators.
I am still trying to get over the idea that there isn’t a fusion where there’s supposed to be a fusion.
Hypothetically…if the graft has dissolved, (which it would have had to have done in the last 6.5 years since the second surgery, since they surely would have noticed that, right?), other than the pain I’m having, is there a danger to not doing anything about it?
If there was a graft that dissolved, there is generally no danger to this level. Flexion/extension X-rays could be helpful to look for instability but you have lived with this so long that I assume the level is stable. There still should be some evidence of an attempt at a prior fusion based on X-rays and MRI.The operative report should be quite interesting to read.
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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