[geckogirl]

#35848

Hi Dr. Corenman,
I would appreciate your opinion on my current symptoms and MRI report.
I have all the symptoms you mention in your section on Cervical Degenerative Facet Disease except for instability pain. These symptoms are primarily on the left side with minimal symptoms on the right.
Neck pain is as you describe, deep dull local pain which is constant, sharp pain with certain movements which also prevents movement for a second or two, and stiffness and joint noises. The stiffness and pain have caused decreased range of motion. The pain radiates into the shoulders and I have pain in the scapular region.
Headaches include pain at the base of the skull as well as around the left eye, I also experience facial tingling and itching/tingling at the back of the head. Head pain is constant and occasionally severe.
Arm pain – I do occasionally have upper arm pain but this is minimal. My arms are quick to fatigue which has prevented PT progression beyond basic arm exercises. I also have tingling in the forearm and into the hand as well as a decrease in grip strength.
In addition, I have outside lower leg pain, toe pain, and tingling in the foot.
I am currently seeing a spine/pain management physician and his initial assessment has focus on 2 areas: severe left C23 facet joint arthrosis (interestingly, this is not noted on the MRI report) and diffuse moderate facet joint arthrosis; and left posterolateral extrusion C67 with moderate to severe left C7 foraminal stenosis.

I have had a C2,3,4 diagnostic injection with only 25% relief. I then had 2 therapeutic C7-T1 interlaminar epidural steroid injections; the first provided good improvement for 6 days, the 2nd provided moderate improvement for 4 weeks (Interesting, the leg/toe pain also improved although the tingling remains). I then had a C4,5,6 diagnostic injection with significant relief and will have my second injection this coming week. If successful, an RFA will be performed.

Do you feel this is the best approach and would you think surgery might be required in the future?
MRI Report
FINDINGS
The visualized portions of the posterior fossa and craniocervical junction are normal. Normal signal remains in the cord. Following gadolinium enhancement, there is no abnormal focus of enhancement seen.

Disc levels:
At C2-3, the disc is unremarkable.
At C3-4, there is loss of disc height. There is a shallow disc osteophyte complex and bilateral uncovertebral osteophytes. There is moderate right foraminal encroachment moderate to severe left foraminal encroachment. There is mild-to-moderate central stenosis.
At C4-5, there is a shallow disc osteophyte complex. Small uncovertebral osteophytes with mild-to-moderate right foraminal encroachment moderate left foraminal encroachment. Mild-to-moderate central stenosis.
At C5-6, there is OPLL extending down to C6-7. There is a shallow disc osteophyte complex. There is mild-to-moderate central stenosis and bilateral foraminal encroachment
At C6-7, there is fatty change in the endplates. There is left greater than right uncovertebral arthropathy and moderate to severe left foraminal encroachment.
At C7-T1, the disc is unremarkable. There is facet arthropathy

IMPRESSION
No cord lesions. No abnormal focus of enhancement. Degenerative spine disease, as detailed above. At C3-4 there is moderate right foraminal encroachment moderate to severe left foraminal encroachment. At C4-5 there is moderate left foraminal encroachment. At C6-7 there is moderate to severe left foraminal encroachment.

Thank you for your time.

[Donald Corenman, MD, DC]

#35849

You do have some significant problems in nerve and maybe even spinal cord compression. Part of the information missing is your physical examination, part is what structures were the target for the injections and part is what side your symptoms are on.

Did you have deep tendon reflex changes (DTR) on exam? Did you have sensory changes in your arms? Did you have any weakness of muscle groups upon examination? Did you have long tract signs (hyperreflexia, clonus, Hoffman’s sign) present?

WHen you note levels for injections, are these medial branch blocks (MBB), facet injections, selective nerve root blocks or epidural injections.

When you developed “Arm pain – I do occasionally have upper arm pain but this is minimal. My arms are quick to fatigue which has prevented PT progression beyond basic arm exercises. I also have tingling in the forearm and into the hand as well as a decrease in grip strength”, what sides?

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.

[geckogirl]

#35850

Thank you for reply. Hopefully the following information answers your questions.

Did you have deep tendon reflex changes (DTR) on exam? Reflexes: Right/left biceps, brachioradialis, triceps absent/absent, patellar and Achilles 2/2.
Did you have sensory changes in your arms? Light touch intact bilaterally C5-T1.
Did you have any weakness of muscle groups upon examination? Right/left shoulder abduction, elbow flexion, extension, wrist extension, finger abduction and thumb opposition 5/5.
Did you have long tract signs (hyperreflexia, clonus, Hoffman’s sign) present? No

WHen you note levels for injections, are these medial branch blocks (MBB), facet injections, selective nerve root blocks or epidural injections.
Diagnostic C2,3,4 medial branch block – Only 25% relief
Therapeutic C7-T1 interlaminar epidural steroid injection #1 – good relief for 6 days
Therapeutic C7-T1 interlaminar epidural steroid injection #2 – moderate relief for 4 weeks
Diagnostic C4 and C5 and C6 medial branch blockade – 95% relief – 2nd injection will be this week.

When you developed “Arm pain – I do occasionally have upper arm pain but this is minimal. My arms are quick to fatigue which has prevented PT progression beyond basic arm exercises. I also have tingling in the forearm and into the hand as well as a decrease in grip strength”, what sides? Tingling in forearm/hand is on the left side. Upper arm fatigue occurs in both arms but worse on the left side.

I did have an EMG which indicated mild carpal tunnel.
There is a left, mild in degree median neuropathy at the wrist that may be associated with carpal tunnel syndrome. There is no electrophysiologic evidence for right or left cervical radiculopathies, brachial plexopathies or other evidence for neuromuscular disease.

The neurologist and 2 spine specialists did not feel the canal stenosis noted on MRI was significant enough to cause my symptoms.

[geckogirl]

#35852

I should note that the Therapeutic C7-T1 interlaminar epidural steroid injections were midline and the Diagnostic MBB’s were on the left side.

[geckogirl]

#35857

Thank you for reply. Hopefully the following information answers your questions.

Did you have deep tendon reflex changes (DTR) on exam? Reflexes: Right/left biceps, brachioradialis, triceps absent/absent, patellar and Achilles 2/2.
Did you have sensory changes in your arms? Light touch intact bilaterally C5-T1.
Did you have any weakness of muscle groups upon examination? Right/left shoulder abduction, elbow flexion, extension, wrist extension, finger abduction and thumb opposition 5/5.
Did you have long tract signs (hyperreflexia, clonus, Hoffman’s sign) present? No

WHen you note levels for injections, are these medial branch blocks (MBB), facet injections, selective nerve root blocks or epidural injections.
Diagnostic C2,3,4 medial branch block, Left – Only 25% relief
Therapeutic C7-T1 interlaminar epidural steroid injection #1, Midline – good relief for 6 days
Therapeutic C7-T1 interlaminar epidural steroid injection #2, Midline– moderate relief for 4 weeks
Diagnostic #1 C4 and C5 and C6 medial branch blockade Left– 95% relief
Diagnostic #2 C4 and C5 and C6 medial branch blockade Left– 95% relief

When you developed “Arm pain – I do occasionally have upper arm pain but this is minimal. My arms are quick to fatigue which has prevented PT progression beyond basic arm exercises. I also have tingling in the forearm and into the hand as well as a decrease in grip strength”, what sides? Tingling in forearm/hand is on the left side. Upper arm fatigue occurs in both arms but worse on the left side.

I did have an EMG which indicated mild carpal tunnel.
There is a left, mild in degree median neuropathy at the wrist that may be associated with carpal tunnel syndrome. There is no electrophysiologic evidence for right or left cervical radiculopathies, brachial plexopathies or other evidence for neuromuscular disease.

The neurologist and 2 spine specialists did not feel the canal stenosis noted on MRI was significant enough to cause my symptoms.

Since the 2nd C4,5,6 MBB was successful I will be scheduling RFA. Do you feel this is the best approach and would you think surgery might be required in the future?

[Donald Corenman, MD, DC]

#35860

Based upon your reported examination, you have no focal findings of significant nerve root compression. This is confirmed by the EMG.

Your significant relief from the MBB indicates that the facets are a large cause of your local pain (Diagnostic #1 C4 and C5 and C6 medial branch blockade Left– 95% relief). Radiofrequency ablations sound like a good next step.

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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