[Duke]

#32387

Dr Corenman,

I have had both MRI’s of the brain and neck; I am a long time patient with migraines but I’m taking many meds with limited success. I’m on Cymbalta 60 mg 2x daily, Lyrica 2x daily, Emigality for 4 months, and Botox just three weeks ago. I also have had 2 epidurals in back for cervical spine. After the Botox and last epidural my headaches were better and almost non existent for 2 weeks. But, now the headache is back again; 3/10 severity, right side of head only, cheekbone, and around eye sometimes.This headache had been around largely for 4 months daily but lifted for the aforementioned 2 week period approximately just after Botox and Epidural. Doesn’t seem like Lyrica or Emagality having any impact. One dr. says Triginmal Neuragia, tested for Temporal arthritis negative, and a final dr. says migraine. By the way, my neck generally feels very tight at the base of my skull.

Here’s my question: Does it sound like Migraine or could it be C2 & C3 and/or C3 & C4 { Please see both cervical and brain MRI’s below. I truly appreciate your professionalism and willingness to help.

Exam Performed: MRI Cervical Spine wo IV
Exam Date/Time: 11/21/19
Date of Service: 11/21/19 1715
Req #: 1121-0195
Accession #: 11364558.001SMM
Dictating Dr: Sheila Wilson MD
Primary Dr: Physician Not On Staff
HISTORY: Neck pain, spinal stenosis.

COMPARISON: December 19, 2018

TECHNIQUE: Multiplanar, multisequence MRI were acquired of the cervical spine
without intravenous contrast.

FINDINGS:

There are multilevel degenerative endplate changes and moderate disc height
loss from C3 through C7. There is chronic mild height loss of the C6 vertebral
body. There is no acute marrow edema. The cervical cord is normal in signal and
caliber.

C2-C3: Small slightly left eccentric broad-based disc osteophyte complex
without spinal canal stenosis. Patent bilateral neural foramina.

C3-C4: Large broad-based disc osteophyte complex and bilateral uncovertebral
joint osteophytes resulting in mass effect upon the ventral spinal cord and
moderate spinal canal stenosis. Moderate bilateral facet arthropathy. Severe
left and moderate right neural foraminal narrowing.

C4-C5: Moderate broad-based disc osteophyte complex and right uncovertebral
joint osteophyte. Effacement of the ventral thecal sac without spinal canal
stenosis. Moderate right and mild left facet arthropathy. Moderate right and
mild left neural foraminal narrowing.

C5-C6: Large broad-based left eccentric disc osteophyte complex and bilateral
uncovertebral joint osteophytes effacing the ventral thecal sac without spinal
canal stenosis. Mild bilateral facet arthropathy. Moderate left and mild to
moderate right neural foraminal narrowing.

C6-C7: Small broad-based disc ossific complex and bilateral uncovertebral
joint osteophytes. Patent spinal canal. Mild bilateral facet arthropathy.
Moderate right and mild left neural foraminal narrowing.

C7-T1: No disc protrusion, neural foraminal narrowing or spinal canal stenosis.

IMPRESSION:

1. Multilevel moderate to severe degenerative changes, most pronounced from
C3 through C7, similar to December 2018

2. Multilevel disc osteophyte complexes, most pronounced at C3-C4 and C5-C6
resulting in mass effect upon the ventral spinal cord and moderate spinal canal
stenosis at C3-C4.

3. Multilevel mild to moderate neural foraminal narrowing which is moderate
to severe at C3-C4.

4. Mild to moderate multilevel facet arthropathy.

Admitting Dr:
Ordering Dr: Benner, Eric O MD
Admit Date/Time: 11/01/19 1419

Exam Performed: MRI Brain wwo IV
Exam Date/Time: 11/01/19
Date of Service: 11/01/19 1445
Req #: 1101-0158
Accession #: 11240003.001SMM
Dictating Dr: Sheila Wilson MD
Primary Dr: Benner,Eric O
HISTORY: Migraine syndrome.

COMPARISON: MRI pituitary dated September 15, 2018

TECHNIQUE: MRI of the brain performed with T1, T2, gradient-echo, and
diffusion weighted images/ ADC maps. Postcontrast sequences were also
performed.

FINDINGS:

There is mild cerebral volume loss and ex vacuo dilatation of ventricular
system. There are scattered punctate foci of increased signal intensity within
the periventricular and deep subcortical white matter on the T2/FLAIR sequences
which are nonspecific; however, they are most likely secondary to chronic small
vessel disease. There is no evidence of restricted diffusion to suggest an
acute infarct, midline shift or mass effect. There are no blood products on the
gradient echo images. Normal intracranial flow-voids are seen.

The visualized paranasal sinuses are clear.

There is no pathologic enhancement identified.

Degenerative changes are noted within the upper cervical spine.

IMPRESSION:

1. No acute intracranial process.

2. Mild cerebral atrophy and mild chronic small vessel disease, similar to
2018.

3. No pathologic enhancement identified.

[Donald Corenman, MD, DC]

#32388

You note: “headache is back again; 3/10 severity, right side of head only, cheekbone, and around eye…By the way, my neck generally feels very tight at the base of my skull.

Your MRI report summary:
C2-C3: (no mention of facet integrity)
C3-C4: mass effect upon the ventral spinal cord and moderate spinal canal stenosis. Moderate bilateral facet arthropathy. Severe left and moderate right neural foraminal narrowing.
C4-C5: without spinal canal stenosis. Moderate right and mild left facet arthropathy. Moderate right andmild left neural foraminal narrowing.
C5-C6: without spinal canal stenosis. Mild bilateral facet arthropathy. Moderate left and mild to
moderate right neural foraminal narrowing.
C6-C7:. Mild bilateral facet arthropathy. Moderate right and mild left neural foraminal narrowing.

Your brain MRI notes: There is mild cerebral volume loss and ex vacuo dilatation of ventricular
system. There are scattered punctate foci of increased signal intensity within the periventricular and deep subcortical white matter on the T2/FLAIR sequences
which are nonspecific; however, they are most likely secondary to chronic small
vessel disease”

You must have some hypertension as you have some nonspecific findings> I am not an expert on the brain but there are no findings I can tell that would lead to a headache due to brain findings.

Right sided headaches from the base of the skull could be related to facet disease which was not discussed in the MRI report and could mean there were no findings or the upper joints were not read.

If I assume that the upper two levels are “OK” and the symptoms could be generated by the C2-3 and C3-4 facets which are “arthritic enough” (“Moderate bilateral facet arthropathy”), then the next step would be diagnostic facet blocks and then potential RFA.

See https://neckandback.com/treatments/facet-blocks-and-rhizotomies-neck/ and
https://neckandback.com/treatments/pain-diary-instructions-for-spinal-injections-neck/

If that pathway is non-diagnostic, it is possible that the C3-4 level could be a pain generator (“Severe left and moderate right neural foraminal narrowing”) or even C4-5. The would require a selective nerve root block for diagnosis. See https://neckandback.com/treatments/epidural-injections-and-selective-nerve-root-blocks-diagnostic-and-therapeutic-neck/.

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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