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  • cindy2836
    Participant
    Post count: 22

    Hello Doctor. This is the plan I agreed to as 18 months of constant pain is ruining my quality of life. I sure hope it ends the pain at T4 both back and front of my chest. Do you see alot of cases like mine?

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    CHIEF COMPLAINT:
    Mid back and neck pain.

    HISTORY OF PRESENT ILLNESS:
    Patient is a 68-year-old female who has undergone multiple surgeries in
    the past. She underwent ACDF as well as a thoracolumbar fusion at an
    outside institution. She was found to have some adjacent level disease
    and kyphosis and underwent extension into her midthoracic spine with me
    approximately a year and a half ago. She did well but suffered a
    compression fracture at her upper instrumented vertebrae with some
    midthoracic back pain. She has also a backed out screw at C7 with
    pseudoarthrosis at C6-7. She has failed conservative management with
    physical therapy and trigger point injections. She is not interested in
    ablation at this time.

    REVIEW OF SYSTEMS:
    See HPI and prior notes, otherwise negative.

    PHYSICAL EXAM:
    Unable to perform.

    RESULTS REVIEWED:
    Patient’s CT was again reviewed that shows loosening of her T4 screws,
    as well as the backed out C7 ACDF screw.

    ASSESSMENT AND PLAN:
    Patient is a 68-year-old female with a T4 fracture with loosening of her
    screws as well as a pseudoarthrosis at C6-7. We again discussed
    surgical and nonsurgical options. Not sure if surgery will fix all of
    her pain issues but I think she would be a candidate for an extension of
    her fusion to her mid cervical spine. This would likely be a C5-T4
    instrumentation and fusion. We discussed risks, benefits, and
    alternatives of surgery. She will need anesthesia clearance prior to
    surgery.

    This was a telephone encounter. I spent over 15 minutes with the patient, more that half was spent counseling and coordinating care.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8427

    A number of questions have to be answered first before I can give any type of opinion. Why did you have cervical surgery and thoracolumbar surgery? For what symptoms and how did you do after surgery? How long were you pain free until the T4 fracture and what happened to cause the T4 fracture? what does the CT report say about the fusion status below T4 (“loose screws”)? How significant is the C6-7 pseudoarthrosis (CT report)? Have you been checked for osteoporosis? Do you have any other medical problems?

    Dr. Corenman

    cindy2836
    Participant
    Post count: 22

    I do have osteoporosis. Found on Dexa scan 4 years ago when I was 65. Immediately treated with Prolia injections twice a year and I’m current. Neurosurgeon is aware of that fact. I HAD ACDF 2020 due to both arms going numb. It fixed that. I had a revision of my S1-L2 when sciatica pain returned about 6 years ago taking it up to T10 cured the leg pain but within first year I noticed midback pain. Did thoracic epidurals no relief. I don’t have the answers on CT results. My quality of life has suffered these last 18 months. I’m in PM and take Tramadol 4xday. Pain is constant in upper spine at T4 and radiates in to my chest same level.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8427

    I am still somewhat confused. You had a T10-S1 fusion with “loose screws”? Where were the loose screws? You had a T4 osteoporosis fracture that still hurts or do you have referral pain from your C6-7 pseudoarthrosis? This surgeon wants to carry the fusion down from the C6-7 pseudoarthrosis to include T4 or down to T10? Did you have any diagnostic blocks to determine pain generators?

    Dr. Corenman

    cindy2836
    Participant
    Post count: 22

    I had an add on extension to the S1-T10 taking it up to T4 18 months ago. No I have not had diagnostic testing for pain such as ablation but I did have short term success with trigger point injections at T4 but would wear off quickly. The loose screws at C7 were a bonus find on tspine imaging. Surgeon said if it’s not causing me trouble swallowing we will watch and wait. This is the first time I heard non union at that C level. I believe the compression fracture which wedged within 6 weeks of the extension will never heal on its own without surgery. Then the kyphosis issue.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8427

    So, C6-7 has loose anterior screws due to a pseudoarthrosis, you are fused from S1 to T4 and have a new compression fracture of T4 due to the stress loading of the lower construct and osteoporosis.The picture is becoming clearer.

    With a pseudo at C6-7, and a new compression fracture at T4 where the fusion ends, it looks like your best solution is to extend the fusion up to the cervical spine. This fixes T4 and C6-7, and gets rid of that stress riser. Make sure those anterior C6-7 screws are not prominent as not to irritate the esophagus.

    Dr. Corenman

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