[drdave35]

#6940

Dear Dr. Corenman,

Thank you very much for your kind and wise advice regarding my previous surgeon having discharged me from care at 8 weeks post C5-6, C6-7 ACDF with allograft and plating.

It is worthwhile to note that I have been previously diagnosed with a chronic B-12 deficiency (treated with cyanocobalamin injections every month) and a vitamin D insufficiency (D level of “14” on pre-op lab results, for which I now take 5000 I.U. of D-3 daily). This is apparently due to an absorption problem caused by years of using proton pump inhibitors for sever GERD. Could be a factor in some of the neurological symptoms…I have a first neurology appointment coming-up in a few weeks, along with EMG/NCV’s scheduled for both upper and lower extremities.

I was lucky enough to have been accepted for care by another orthopedic spine surgeon last week.

He reviewed all of my findings, took plain x-rays, and my post-op diagnosis remains as Cervical foraminal stenosis, cervical myelopathy (based on clinical examination, etc.)

The physician recommended an immediate CT/Myelogram, and stated there was posterior lipping and possible spondylolisthesis of C6-7. He could not tell from the plain films if fusion had begun (11 weeks post-op).

When I mentioned the myelogram order to my internist, he told me that he thinks it is contra-indicated in my case, due to having had two previous lumbar surgeries (he felt the lumbar puncture would not seal, due to scarring of the dura), and that since I already have a diagnosis of myelopathy and multiple nerve root compression (symptoms have not resolved at all post-ACDF), that the myelogram dye may well leave me much worse-off than I am at present.

Aside from deep “bone-pain” type headaches every day which seem to be associated with neck position (replicable by tilting my head left or right, or turning my head to the right), I persist with: bilateral arm pain, bilateral arm numbness, rather severe muscle spasms in neck, shoulders, mid-back between shoulder blades, along with leg and arm spasticities (spontaneous painful contractures of toes, feet, fingers, and wrists which are intermittent, but which do release with manual re-positioning back to a neutral position), neck pain, radiating scalp and facial pain.

That said, I am SCARED TO DEATH of undergoing a myelogram.

Between the lumbar puncture, the potential (probable) spinal headaches, blood patches, CSF leaks, being bedridden, possible inflammatory nerve response, etc…I am highly unlikely to undergo the requested procedure…I am barely hanging-on here pain-wise, and I just can’t risk being in more pain or being any more disabled than I currently am.

So, I asked my new orthopedic spine surgeon for an alternative diagnostic (such as MRI). He had his P.A. call me and tell me there is no alternative to the myelogram “because you have had a cervical fusion”.

I understand that the titanium plate can cause artifact on MRI, but isn’t there something else he can order to obtain relatively clear visualization of the bone growth and/or nerve root and spinal cord compression without putting me through a myelogram?

I feel I am one again “stuck” in my treatment, as the doctor will not order a bone growth stimulator, P/T, or any other treatment until I undergo the myelogram, and only the myelogram.

Once again, I am not trying to be a “difficult” patient, but I honestly am not willing to put myself in a position to become (potentially) sick and further disabled from the myelogram.

Your valuable insight would be greatly appreciated, as to any alternative diagnostics you would recommend in this situation.

Thank You,

D.S.

[SpinelessWench]

#6941

Dear D.S.,

As one cervically-fused patient to another, I too have been put in the position of electing for a myelogram, or “nothing”… I’m fused with dynamic stabilization instrumentation from C2 to T2, as well as L3 to S1… Just a few weeks ago, my orthopedic surgeon ordered a standard MRI of my lumbar spine, with gadolinium enhancement midway through via intravenous injection. The radiologist did note in his report a, “significant amount of artifact” obscuring any assessment of L4 down… I’m wondering if a myelogram would’ve provided better clarity in identifying stenosis at those levels. Given the artifact in my spine, I’m also wondering why my orthopedist didn’t elect for the myelogram to begin with.

Hopefully, Dr. Corenman can provide some insight… Good luck to you.

S.W., NC

[Donald Corenman, MD, DC]

#6961

A myelogram is not the miserable test that you generally think of. I do use these tests when necessary and most patients do not have significant after-effects.

Part of the successful myelogram is the skill of the radiologist who performs the injection. If you have a skilled, meticulous radiologist with lots of experience, the injection can go very well with very little risk of dural leak. Prior lower back surgery does not preclude a myelogram as long as the L2-L3 level has had no prior surgery.

If you really are against the myelogram, you could first have an MRI of the cervical spine with an experienced radiology technician on a very good MRI machine. I typically will get an MRI as the first test when I work up a patient with prior surgery and it is unusual that these images can’t be interpreted.

If the images are good (the canal can be seen), then a plain CT scan by itself can be used to determine the status of the fusion and any bone in the canal. If the images obscure the canal, then a CT myelogram is necessary.

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.

[wgreenlee]

#22402

What dos a myelogram indicate that a MRI wouldn’t?

[Donald Corenman, MD, DC]

#22404

Generally, the MRI has more information than the myelogram and I am assuming that the myelogram is being performed with a CT scan. The only questions that the CT scan can answer are fusion status and if the MRI is obscured by metal artifact from prior instrument implantation, the MRI will reveal information about the canal that generally won’t be obscured.

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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