[mharbison]

#28938

Hello Dr. Corenman,

First I want to say thank you for all that you do! It was watching your videos on YouTube that helped me to make the decision to have my first spinal fusion done and to do so without too much fear. I am now seeking some answers to my current medical situation that has me living in even worse pain than before.
I am now 38 years old and about to be married to the love of my life. I am so desperately wanting to be back to some semblance of “normal” as I start my new family. I live every day with severe pain in my neck and back. This pain radiates like lightning down my right arm into my thumb and finger, along with tingling and numbness quite a bit. The pain also radiates down into my left leg, sometimes causing me to fall. (It goes numb at times, and just won’t work normally)

I have had previous lumbar and cervical fusions. However, I was in a car accident and hit from behind- which is what I believe led to further damage. I had been diagnosed with spondylolisthesis years prior to my spinal fusions.

I currently have one doctor that is suggesting that I undergo another cervical fusion and had recommended that I get facet injections at L4-5. I did have the facet joint injections done but to no avail. I then went back to my previous surgeon that did my original cervical fusion and asked for a second opinion, just to make sure I was making the right decision. (I had not gone back to the original surgeon in the first place due to scheduling conflicts at first) The original surgeon said that I did need to have the cervical fusion surgery at some point, but that he did not recommend it now since I am so young. He said it would be smarter to live with the pain until I am much older, as the chances of having to have additional fusions are higher once you start to fuse more than one level. I am having a hard time swallowing that particular answer because what does that do for my quality of life in the meantime? I have tried all of the non-surgical options that have been made available to me, and like I mentioned right at the beginning, I want to have a better quality of life NOW, and not when I am 70- as he suggested. I am starting a new chapter in my life and I want to be able to be the husband that I need to be and the father that I want to be.

Here is the work-up from the Dr recommending the cervical fusion:

CHIEF COMPLAINTS: neck, lumbar spine

HISTORY OF PRESENT ILLNESS:

On 04/10/2017, Michael, a 38 year old male, presented for evaluation of his neck.

CERVICAL SPINE:

Problem: 95% Neck pain and 5% Right arm pain

Onset (exact): 10/10/2016

Cause: motor vehicle accident

Quality of symptoms: constant (~90% of the time) sharp pain, constant (~90% of the time) aching pain and
constant (~90% of the time) stabbing pain

Radiation: right hand

Intensity: severe (rated 8/10)

Aggravating Factors: Sitting, Standing, Walking, Lying down, Bending forward and Bending backwards

Relieving Factors: nothing

Associated signs/symptoms: right sided numbness, right sided weakness and right sided spasm

Prior diagnosis: herniated disc and neck pain

Prior Tests: MRI and CT Scan showing a herniated disc

Prior Treatments: physical therapy without relief, NSAID without relief, chiropractic without relief, ESI without relief and Facet Blocks without relief

Patent Denies: bowel or bladder dysfunction and gait disturbance

LOWER BACK:

95% back pain and 5% L leg pain

Onset (exact): 10/10/2016

Mechanism: motor vehicle accident

Quality: constant sharp pain, constant aching pain and constant stabbing Radiation: leg left

Intensity: severe (rated 9/10)

Aggravating Factors: sitting, standing, walking, lying flat, bending forward and bending back

Relieving Factor: nothing

Associated S/S: left sided numbness and left sided weakness

Prior diagnosis: back pain and fusion

Prior Tests: CT scan

Prior Treatment: fusion surgery with some relief and physical therapy without relief

ALLERGIES:

1. Zofran- Intolerance-unknown

Currently not taking any medications.

MEDICAL HISTORY:

Illnesses – High Blood Pressure; Accidents – no injuries of consequence;

FAMILY HISTORY:

1. Family Member

– Ischemic heart disease – Stroke

SOCIAL HISTORY:

Alcohol Use – denies drinking Smoking – denies smoking Exercise – moderately active Lifestyle – average stress

REVIEW OF SYSTEMS:

GENERAL – Denies fever, or chills
SKIN – Denies rash, new skin lesions, or change in moles
EYES – Denies blurred vision, or change in visual acuity
EARS – Denies ear pain, or difficulty hearing
NOSE – Denies nasal congestion, discharge, or bleeding
MOUTH – Denies sore throat, or difficulty swallowing
NECK – Denies pain or swelling
RESPIRATORY- asthma

CARDIOVASCULAR – Denies palpitations, chest pain, orthopnea, PND, peripheral edema, syncope or claudication

GASTROINTESTINAL – Denies abdominal pain, melena, or bright red blood,nausea, vomiting, diarrhea, constipation

GENITOURINARY- Denies dysuria, frequency of urination, urgency, or hesitancy

MUSCULOSKELETAL – see HPI

NEUROLOGICAL – headache(s)

PSYCHIATRIC-depression

ENDOCRINE – Denies heat or cold intolerance, weight loss or gain, increasing thirst

HEMATO-IMMUNOLOGIC – Denies easy bruising, bleeding, oral ulcerations or recurrent infections

EXAMINATION:

CERVICAL SPINE:

Skin – Left ACF scar healed

Gait – Patient ambulates without a limp

Inspection – Normal attitude, no swelling, no scars

Palpation – moderate trapezius spasm

ROM – painful cervical rotation, painful cervical flexion and painful cervical extension

Special Tests – positive Mild Spurling’s test Right

Strength – right deltoid 4/5 and right wrist extensor 4/5

Sensory – right abnormal C5 C6 C7

Pulses – 2+ radial pulses

Reflexes – 2+ biceps, brachioradialis, and triceps reflexes, symmetrical reflexes Shoulder – normal shoulder bilateral

Lymph nodes – none palpable

THORACIC/LUMBAR SPINE:

Thoracic Spine
Spinous process tenderness – Non-tender throughout
Paravertebral muscle spasm – moderate
Kyphosis – Normal
Lumbar Spine
Scars – posterior healed

Lum. Spinous process tender – moderate diffuse L4 tenderness, moderate diffuse L5 tenderness and moderate diffuse S1 tenderness

Lum. posterior superior iliac spine – Non-tender

Lum. paravetrebral muscle spasm – moderate bilateral

Lordosis – Normal lordosis

Scoliosis – None

Lum. motion – painful decreased

Pelvis – Level in standing position

Fabere – Negative bilaterally

Hip motion – Normal, painless ROM bilaterally

Sitting straight leg raising – bilateral positive mild

Supine straight leg raising – Negative bilaterally

Lasegue – Negative bilaterally

Femoral nerve stretch test – Negative bilaterally

Gait – Ambulates without a limp

Motor exam- right deficit tibialis anterior 4/5, right deficit extensor hallicis longus 4/5 and right deficit peroneals 4/5

Reflex Knee Jerk R/L – Bilateral knee jerk symmetric, bilateral ankle jerk symmetric

Babinski – Bilateral downgoing

Sensory – left abnormal L4 L5 S1

Peripheral pulses – Pedal pulses intact bilaterally

ASSESSMENT:
1. Cervical Disc Disorder With Radiculopathy, High Cervical Region, New, M50.11
2. Arthrodesis Status, Stable, Z98.1

PLAN:

TREATMENT OPTIONS DISCUSSED (Cervical Spine):

Surgery – recommendations are for ACDF C4-5 C5-6

Comments – risks, benefits, and alternatives have been discussed and has failed all non-operative treatment

TREATMENT OPTIONS DISCUSSED (Spine):

Injection – Recommend facet injections bilateral L4-5
——————————————————————————-

Here are the imaging results:

There is excellent opacification of the cervical thecal sac by the myleographic contrast.
There is an intact anterior fusion plate and interbody screws and fusion plug at the c6-7 level. There is straightening of the normal cervical lordosis which could be positional or due to muscle spasm. There is no fracture or destructive lesion.

cC2-3: Minimal bilateral unconvertebral spurring not resulting in significant foraminal encroachment, no disc protrusion or acquired stenosis centrally

C3-4: Mild bilateral unconvertebral spurring not resulting in significant foraminal encroachment, no disc protrusion or acquired stenosis centrally

C4-5: 3 millimeter AP right paracentral/right lateral disc protrusion resulting in mild right paracentral acquired stenosis and mild encroachment on the central portion of the right C4-5 foramen. Mild right-sided uncovertebral spurring also contributing to the mild right foraminal encroachment

C5-6: Mild circumferential disc bulge barely flattening the ventral thecal sac resulting in minimal central acquired stenosis. No foraminal encroachment or focal disc protrusion

C6-7: Fusion plug is not yet completely incorporated but alignment is normal. There is no recurrent or residual disc protrusion, acquired stenosis, or foraminal encroachment.

C7-T1: Normal

IMPRESSION:

Status post anterior fusion C6-7 with no recurrent or residual stenosis or foraminal encroachment at the fused level
Small right paracentral disc protrusion C4-5 with associated right-sided uncovertebral spurring resulting in mild right paracentral acquired stenosis and mild right foraminal encroachment.
Mild degenerative changes C2-3, C3-4, and C5-6 as detailed.

I am still waiting to get the results of my newest lumbar MRI. I will post those when available.
What are your thoughts Dr. Corenman? I would really love to know what you think about this. I want to do what is right, and what is best for me. At the same time, I want to find relief from this hell. Thank you for empowering us with your knowledge and expertise so that we are able to make informed decisions about our healthcare!

Truly,

Michael

[mharbison]

#28977

Dr. Corenman,

Just had a new cervical and lumbar MRI done yesterday. I will post the new results here tomorrow.
I look forward to hearing from you!
Michael

[mharbison]

#28978

Hello Dr. Corenman,

Here is my newest Lumbar and Cervical MRI reports. Might explain some of my pain!

MRI CERVICAL SPINE WITHOUT CONTRAST: 8/18/2018
HISTORY: Chronic neck pain with right arm radiculopathy.
COMPARISON: CT myelogram 03/27/2017
TECHNIQUE: At 1.5 Tesla, appropriate pulse sequences were employed in multiple planes.
FINDINGS:
Marrow and Alignment: Marrow signal is normal. Craniocervical relationships appear normal. The spine is minimally straightened.

Canal and Foramina:
C2-C3: Neural foramina are moderately narrow with potential for impingement.
C3-C4: Neural foramina are narrowed with potential for impingement.
C4-C5: Modest right paracentral/lateral protrusion slightly contacts the cord. The canal is patent. The right neural foramen is narrow with likely neurologic impingement. The left neural foramen is moderately narrow with potential for impingement. Findings appear similar to the prior study.
C5-C6: Moderate protrusion slightly impinges upon the cord. The canal is patent. Neural foramina are slightly narrow.
C6-C7: Intact appearing fusion. Canal and foramina are patent.
C7-Tl: Unremarkable.

Cord: The spinal cord otherwise appears normal in morphology and signal.

Paraspinal Soft Tissues: Modest nonspecific cervical adenopathy.

IMPRESSION:
Straightening of the spine. Intact appearing C6-C7 fusion in normal anatomic alignment.
Modest right paracentral and lateral C4-C5 protrusion slightly contacting the cord and narrowing the right neural foramen with likely neurologic impingement.
Moderate C5-C6 protrusion slightly impinging upon the cord.
Moderate multilevel neuroforaminal narrowing with potential for impingement as described above. Milder degenerative changes at other levels.

MRI LUMBAR SPINE WITHOUT CONTRAST: 8/18/2018
HISTORY : Chronic low back pain with left leg radiculopathy.
COMPARISON: MRI 12/16/2016. CT myelogram 03/20/1717
TECHNIQUE: At 1.5 Tesla, appropriate pulse sequences were employed in multiple planes.

FINDINGS:

General: The vertebral bodies are well maintained and show normal signal characteristics. 5 mm L5-S 1 anterolisthesis as on prior CT. Fusion at this level appears intact.

Conus: The conus medullaris shows normal position, contour, and signal content. The visualized portions of the lower thoracic spine do not show any significant abnormalities.

Canal and Foramina:

L1 -L2: There is now an 8 mm left paracentral anterior extradural soft tissue lesion extending from the disc space cephalad likely representing a superiorly extruded herniation fragment. The thecal sac adjacently is deformed with impingement upon neurologic structures within the lateral recess. There is also potential for impingement upon the small portion of the exiting nerve root as it enters the neural foramen. The right neural foramen and spinal canal proper are acceptably patent.
L2-L3: The disc bulges slightly.
L3-L4: The disc bulges slightly. Mild posterior element hypertrophic changes are seen.
L4-L5: Canal and foramina appear patent.
L5-S1: Canal and foramina are patent. Moderate posterior element hypertrophic changes are seen.

SoftTissues: The paraspinous soft tissues and visualized portions of the retroperitoneum are unremarkable.

IMPRESSION:
Interval enlargement of left paracentral L1-L2 herniation, now with pronounced cephalad extrusion deforming the thecal sac and encroaching upon the lateral recess and a portion of the left neural foramen.

Intact appearing LS-S1 fusion with unchanged 5 mm anterolisthesis

I apologize if there are any typos in the above reports. I had to scan-to-text from a .pdf file as the pdf would not allow me to copy and paste. The text recognition was not the best, so I tried to correct as best as I could. I am just wondering if I should proceed with my surgeons’ advice to have surgery, especially after seeing the newest MRI, or not. The pain is completely unbearable. I am at my wit’s end.
Thanks so much
Michael

[mharbison]

#29367

Dr,

Just wondering if you have over-looked my post. Anxious to hear your opinion.
Thanks,

[Donald Corenman, MD, DC]

#29379

Sorry for my tardy reply.

You note; “I live every day with severe pain in my neck and back. This pain radiates like lightning down my right arm into my thumb and finger, along with tingling and numbness quite a bit”. Your doctors report; “Problem: 95% Neck pain and 5% Right arm pain, Strength – right deltoid 4/5 and right wrist extensor 4/5”, “Sensory – right abnormal C5 C6 C7” C6-7: Radiological evaluation: “Fusion plug is not yet completely incorporated but alignment is normal. There is no recurrent or residual disc protrusion, acquired stenosis, or foraminal encroachment.

For your cervical spine, your doctor notes 95% neck pain and only 5% arm pain. This means that the arm pain is ignorable and your neck pain is the focal pain generator. There was a comment that the fusion at C6-7 was “not incorporated” possibly indicating a pseudoarthrosis. This could be most of the cause of your neck pain and needs to break looked into with a CT scan.

Lumbar spine

The pain also; “radiates down into my left leg, sometimes causing me to fall. (It goes numb at times, and just won’t work normally)” “Motor exam- right deficit tibialis anterior 4/5, right deficit extensor hallicis longus 4/5 and right deficit peroneals 4/5”

Your MRI notes; “L1 -L2: There is now an 8 mm left paracentral anterior extradural soft tissue lesion extending from the disc space cephalad likely representing a superiorly extruded herniation fragment”. Also; “L2-L3: The disc bulges slightly.
L3-L4: The disc bulges slightly. Mild posterior element hypertrophic changes are seen.
L4-L5: Canal and foramina appear patent”. You have a fusion of L5-S1 probably from an isthmic spondylolisthesis you had prior to surgery.

Your lower back pain also is the majority of your current complaints (95%). Could you also have a pseudoarthrosis at your previous fusion level at L5-S1? A CT scan or at least flexion/extension X-rays should be performed.

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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