[leptserkhan]

#5298

Hello Doctor,

I am a healthy 57 year old male with no prior history of surgery or spinal injuries. I am a computer programmer who does spend hours at the computer though, although I also walk briskly daily and exercise. I did suffer from an left shoulder bursitis injury about ten years ago which occasionally flares up but does not give me any significant pain or restriction in use or motion.

In August of this past year I developed severe pain in my left shoulder and tingling with numbness extending down to my left thumb and forefinger. There was minimal cervical spine pain, the most intense was just radiating pain across my left shoulder and down my left arm to my hand. Cold compresses helped as long as they were applied to my cervical spine as I sat at a 45 degree angle. After about a week of compresses the pain diminished but did not go away. I could not sleep on my left side. I had an MRI done and then went to physical therapy. After three+ months of physical therapy I thought I was cured — no more numbness or soreness or pain.

A week later I awoke to a severe pain this time in my spine but without the radiating pain to my left arm or shoulder. This was definitely centered on my upper or middle cervical spine. I applied cold compresses but cannot sleep on my left side again, nor my right side without pain developing at the base of my neck and left shoulder. Here is what the MRI indicated from the August incident (I am writing this in January) — that would be immediately after the first incident (I have not had a recent MRI done for this msot recent incident):

August findings:
Findings: The visualized vertebrae demonstrates normal alignment and marrow signal characteristics. At the C3-C4 level, disk bulge minimally effaces the anterior sub-arachnoid space but does not indent the cord.
At the C4-C5 level, left para central disk protrusion minimally effaces the anterior sub-arachnoid space but does not indent the cord. In addition, right para central disk bulge and right-sided facet joint arthropathic changes are seen to cause mild right foraminal compromise.
At the C5-C6 level, disk bulge with a prominent left paracentral disk protrusion is seen which effaces the anterior subarachnoid space but does not indent the cord.

At the C6-C7 level, left para central disk protrusion effaces the anterior sub arachnoid space and causes trace indentation on the left ventral aspect of the cord. In addition, this disk protrusion extends into the region of the proximal left neural foramen resulting in mild to moderate left foraminal compromise.

There is no signal abnormality seen within the cord.

Normal flow-voids are seen through the visualized vertebral arteries.

The visualized posterior fossa grossly appears unremarkable.

IMPRESSION: Multilevel degenerative changes, most significant at the C6-C7 level as outlined in the body of the report.

Okay, I need English please. This most recent flare up appears more severe in depth of pain. On a scale from 1 – 10 at it’s height the pain was certainly a 15! After four days it has subsided and the cold compresses help.

Would physical therapy help at this acute stage (pain) or should I seriously consider other therapies and would surgery be necessary at this point?

I can provide snapshots of the MRI as I have the disk and am fascinated when I run it and see the inside of my spine.

Thank you kindly,

Lester

[Donald Corenman, MD, DC]

#5301

To recap your history, you developed severe left posterior shoulder pain with paresthesias that radiated into the outside of your left hand about 5 months ago. You sat at a 45 degree angle to get some relief. I imagine that this included some neck flexion (forward head tilt). 3 Months later with PT, your pain was improved. One week later, severe pain developed in your neck with radiation into the left shoulder. I assume the radiation of pain and numbness did not go into the arm.

These symptoms are classic for a radiculopathy, probably of the C6 or C7 nerve. The reason lying down at 45 degrees relieved pain is to flex the neck which opens the foramen (see website under cervical radiculopathy) to relieve pressure on the nerve. I hope you had a thorough examination of your upper extremities to look for deficits in strength, sensation and reflex. This testing is the most sensitive for identifying the nerve root involved and if there is any motor deficit.

Your MRI I assume was performed prior to the new onset of severe neck pain. In my practice, after a new physical examination, a new MRI might be warranted for significant change in symptoms- especially if the physical examination has changed.

The radiologist who read the MRI notes “prominent” left disc herniation at C5-6 but did not comment on whether this caused foraminal compression. He does note a C6-7 HNP, which causes root compression. Either one of these or both could have caused your initial symptoms.

The increased pain four months later could be a recurrent herniation at either of the two levels that now caused some cord deformation. Recurrent herniations occur at the same level as the previous herniations and are due to the same process that caused the initial herniation.

Treatment depends upon the symptoms, the results of the physical examination (motor and cord deficits especially) and MRI/X-ray findings. Without significant motor or spinal cord findings, I would recommend an epidural steroid injection along with physical therapy to a patient with significant neck and shoulder pain who has already undergone previous therapy. Again, a new MRI might be warranted.

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.

[leptserkhan]

#5303

thank you Doctor!

I will ask for another MRI/X-ray and begin physical therapy. After a few days of cold compresses and finally getting some full night sleep I do see some improvement. I also do gentle morning stretches now and wonder if it is okay to sit at a 45 degree angle in a chair or is that exacerbating the condition?

When I attempt to maintain proper alignment in my neck, pain develops, although I must say less so as time goes on.

FYI – they did do a full a thorough examination of upper extremities to look for deficits in strength, sensation and reflex.

Thank you so much for your advice.

Lester.

[Donald Corenman, MD, DC]

#5306

Any position that you can assume to reduce the pain is generally beneficial. “Proper alignment” of the neck causing pain means that there is something compressing the nerve which causes you to develop an antalgic posture (posture to prevent pain) and that is OK. I assume the physical examination did not lead to evidence of any specific nerve root involvement.

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.

[leptserkhan]

#5307

Thank you Doctor Corenman for the useful information. So far I’ve seen a GP and Orthopedic doctor who ordered the MRI. I’ve also seen the Physical Therapist. None of them have indicated that there is any nerve root involvement other than saying degenerative changes C6-C7. But I am going to a spine doctor in the next few days and show him the MRI and see what he has to say. I have taught myself how to read the MRI and I do see what looks like a bone spur at the C6-C7 level but of course I’m not a doctor although I will point this out to the spine doctor.

Thank you so much for your guidance and help. Of course I would see you if I were in Colorado but unfortunately I am in Brooklyn, NY.

[Donald Corenman, MD, DC]

#5308

I think you have made the right decision. Let me know if there is any difference in the spine doctor’s diagnosis and physical examination findings.

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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