[PamC]

#9546

I have longstanding cervical arthritis, at least 10 years in duration, with increasing neck pain, stiffness and dizziness when looking up. Until recently, I’d managed my symptoms successfully with yoga (stretching, muscle strengthening) and ergonomic adjustments (e.g., lowering the height of my computer monitor).

In March and April of this year, I had syncope x3. The first two falls hurt my dignity more than anything else. The third fall was a doozy–double impact, probably first against a kitchen counter and then against the floor hard enough to break my jaw and shatter a couple molars. I actually didn’t become aware of the jaw/dental issues until a couple months later. At the time of the third fall, the problems that had my attention were severe back pain/spasm and left shoulder pain (I’d landed on my left side). As it turned out, the latter issues also waited a couple months for evaluation.

First, my PCP ordered a 30-day cardiac event monitor that revealed bradycardia (as low as 12 bpm), sinus pauses (as long as 6 seconds) and episodic complete heart block. Pretty crazy. I had no history of heart disease and none of the usual risk factors (I just turned 55, but I weigh 105 pounds, no diabetes, no hypertension, lipids are fine, etc.) But sometimes things just are what they are, so I ended up with a dual chamber pacemaker (placed on May 28th).

And then (with no previous history of clotting problems), I developed a significant DVT that occluded at least four veins–internal jugular, subclavian, brachial and axillary. By the time I ended up back in the hospital on June 12th, the clot had actually grown (up my left IJ to the level of the carotid bifurcation and into my left superior vena cava). On readmission to the hospital, I was complaining of significant arm and neck pain and swelling. I also had some “neurologic” symptoms–e.g., headache, dizziness, double vision, left facial numbness. That said, the problem that had scared me into seeking sooner-than-scheduled medical care was left leg weakness and spasticity. I was a little panicked about the latter symptom, had never had anything like that before, and called my daughter at work (she’s a nurse) and that’s how I ended up in the ER and then back in the hospital.

Some of my symptoms resolved once I got adequately anticoagulated, but I continued to complain of left arm, hand and leg weakness. The hospitalist team consulted neurology and my first few neurologic exams were abnormal–e.g., upgoing plantar response on the left, ankle and knee clonus. I noticed on some of my x-ray reports they used terms like “left hemiparesis” (which sounds like an exaggeration–I was complaining of weakness, not paralysis) and left hyperreflexia. On about the fourth hospital day, my neurologic exam began to normalize (e.g., resolution of the hyperreflexia). The neurologist did order several studies (e.g., CT scan of the head, CT scan of the neck, cervical myelogram). I was told the study results were remarkable for arthritis (spondylosis) and there was no good explanation for my arm and leg symptoms. The neurologist speculated I’d had some kind of acute injury that was resolving and I was discharged home to continue anticoagulation and neurologic follow-up.

On follow-up with the neurologist, he told me my neurologic exam was normal. I stood my ground and reasserted my complaints of left arm and leg weakness, so he ordered an EMG, which he told me would be normal but he ordered it, anyway, probably just to pacify me. The EMG showed left C5 radiculopathy and left ulnar neuropathy. The ulnar neuropathy was also an old diagnosis dating back to 2004, but it ended up being my primary diagnosis from this neurologist’s perspective.

I am not complaining about the hospitalist team or the neurologist. The situation confused me as much as anyone else and I still have no idea where the heart block or DVT came from (cardiology insisted the pacemaker placement did not cause the DVT, that I must have an underlying clotting disorder, but work up was entirely negative). And I certainly left the hospital in better shape than on admission.

Over the next few weeks, I worked my way back into usual routines. My back pain/spasm resolved. I went to see a dentist for persistent jaw pain and tooth sensitivity, which led to discover of the healing (nondisplaced) jaw fracture and the broken molars.

I also made repeated trips to orthopedists with complaints of shoulder and arm pain. Since the third fall in April, I’d had persistent pain that I felt in and around my shoulder, as well as spasm of my left deltoid and biceps muscles (which I guess would be more properly called muscle fasciculations because they were/are visible even through my clothing). Occasionally I’d feel pain in my neck, but mostly it was my shoulder and arm. I got increasingly frustrated with ortho–they said my shoulder exam was normal and my x-rays were normal–and my treatment plan consisted of Vicodin and Flexeril. I hate narcotics and Flexeril did nothing but make me drowsy. I finally talked with an orthopedic trauma surgeon (my daughter had worked for him and he’d done my previous hip surgeries for FAI) and obtained a referral to a “really good” orthopedist who (he assured me) would help me figure out what was going on.

And he did, and I’m really happy about it, but also a little baffled.

My CT arthrogram of the shoulder was completely, totally normal.

I was referred back to neurology (a different neurologist, thankfully). The second neurologist said my symptoms made perfect sense to him. He thought the differential was pretty straightforward and could be sleuthed with a repeat EMG and dynamic ultrasound of my elbow. I didn’t have vascular changes so thoracic outlet syndrome was unlikely. The repeat EMG revealed no evidence of traumatic brachial plexopathy (wow, say that three times fast), but did confirm left ulnar neuropathy and an “active” C5 radiculopathy. The ultrasound of my elbow revealed an enlarged ulnar nerve (21 mm at the medial epicondyle compared to 6 mm at the wrist and elsewhere). The nerve was outside the cubital tunnel and we watched it sublux when I flexed my elbow.

I was also referred to a spine surgeon, which was (and still is) a little confusing to me. The orthopedist looked at the CT scan of my neck and my cervical myelogram (in my electronic medical record) and gave me a “heads up” that spine surgery was likely in my future. These were the same films that the hospitalist team and first neurologist reviewed and said seemed “okay” to them except for the arthritis. In any event, I went to see the spine surgeon and was happily surprised to discover that I already knew him. Well, sort of. In 2005, I’d had hip surgery at Duke and did an overnight on the orthopedic floor. Back then, he (the spine surgeon) was the chief resident who came to see me on the floor the night of surgery and again the next day to discharge me. He was super nice, down to earth and had a great sense of humor. I’d liked him a lot, and I have since been told that he’s great and I’m lucky that he’s managing my care (the C-spine portion of it; the shoulder orthopedist who referred me to the other doctors is also an elbow surgeon and will be doing a separate procedure–ulnar nerve transposition I think it’s called).

In any event, the spine surgeon looked at my films (especially my myelogram) and described my problem as complex. He said he’d need to study my films to develop a specific plan, but my surgery would address multiple levels (we talked C4-C7, but possibly more) and would probably require both an anterior and posterior approach. And then he ordered lateral flexion/extension x-rays of my neck, which may or may not add to the information he already had.

And, good Lord, I’m finally getting to my questions.

I went into the electronic medical records system and pulled up my reports. And that’s probably dangerous because I know just enough to ask some probably crazy questions, but here goes:

1. When I read the body of my CT scan report (findings cited below), it sounds like more than “just arthritis.” I presume the “ventral cord compression” is referring to my spinal cord?

CT scan of the neck: “FINDINGS: Multilevel cervical degenerative disc disease is present with variable degrees of encroachment on the central canal. There is prominent posterior bony ridge at the C3-4 disc level producing mild to moderate ventral cord compression. Bony encroachment on multiple cervical foramen is also noted. The latter could be more reliably evaluated with oblique cervical spine plain films if warranted. Please note that CT has low sensitivity for detecting intrinsic pathology of the cervical cord.

The left internal jugular vein is small in caliber and does not show enhancement below the level of the left carotid bifurcation. Soft tissue stranding is present within the left axilla and supraclavicular region compatible with edema which could be on the basis of left subclavian and axillary vein thrombosis although that can’t be confirmed with certainty on this study since IV access for contrast injection was obtained in the right arm.”

2. Cervical myelogram (findings below) describes my overall vertebral heights as unremarkable. There’s apparently minimal anterolistheis of C2 on C3. Otherwise, it sounds like a lot of arthritic changes, more on the right than the left, with occasional mentions of the cord. What is a hemicord? I tried to Google extraforaminal nerve root sleeve diverticulum, but didn’t find much; the little I found makes it seem like that’s an incidental finding of no significance?

“FINDINGS:
Cervical vertebra demonstrate overall unremarkable vertebral body heights. There is a 1.5-2 mm anterolisthesis of C2 on C3. Otherwise alignment appears unremarkable.

At the craniocervical junction, there is no evidence of cerebellar tonsillar ectopia.

No enlargement of the cervical cord is identified.

At C2-3, no focal protrusion or significant disc bulge identified. No stenosis evident. There is mild degenerative change.

At C3-4, there is broad-based posterior osteophytic ridging, compressing the anterior aspect of the thecal sac, though more so on the right. There is slight flattening of the anterior aspect of the cord. Uncovertebral joint hypertrophy bilaterally though greater on the right. Borderline central canal stenosis with right neuroforaminal stenosis.

At C4-5 there is broad posterior osteophytic ridging compressing the anterior aspect of the thecal sac, slightly more so on the right. Narrowing of the intervertebral disc space. Borderline central canal stenosis without definite cord deformity. Moderate right and mild left neuroforaminal stenosis with underfilling of the nerve root sleeve on the left.

At C5-6, disc space narrowing is present with posterior osteophytic ridging, probably compressing anterior aspect of the thecal sac and greater on the right than left. Minimal flattening of the anterior aspect of the right hemicord. Mild central canal stenosis. Degenerative changes primarily in the uncovertebral joints bilaterally with of moderate right and mild left neuroforaminal stenosis.

At C6-7, broad posterior osteophytic ridging, compressing the anterior aspect of the thecal sac though without definite cord deformity. Mild central canal stenosis. Bilateral uncovertebral joint degenerative changes, greater on the right with moderate right and mild-to-moderate left neuroforaminal stenosis associated extraforaminal nerve root sleeve diverticulum on the left, measuring 3 x 5 mm. There is there is underfilling of the of right nerve root sleeve.

At C7-T1, no focal disc protrusion, significant disc bulge, spinal canal or neural foraminal stenosis evident. Small extraforaminal nerve root sleeve diverticula are present.”

3. Flexion/extension views of the neck: “3 mm of anterolisthesis of C2 on C3 that reduces on extension and neutral views, otherwise no acute findings” – is the anterolisthesis an acute finding? I understand the concept of reduction (the alignment is normal in neutral position and in extension) – does that suggest instability of C2, or it is another probably incidental finding?

“Findings and Impression: No acute fractures are identified. There is 3 mm of anterolisthesis of C2 on C3 upon flexion views that reduces upon extension views. There are degenerative changes seen throughout the visualized cervical spine with areas of disc space narrowing and plate osteophyte formation most notable at the C6/C7 level. No prevertebral soft tissue swelling is seen. Incidental seen of the cardiac pacing device.”

Finally, and most importantly, aside from my question about the anterolisthesis, I really don’t see anything acute. I’m not a doctor, obviously, and a lot of this is probably over my head, but I’ve had cervical arthritis for years without any symptoms other than crepitus and neck pain (well, and dizziness when I look up). Certainly no pain or weakness or spasm/fasciculations of my shoulder or arm (or leg, for that matter) and so I really don’t understand “why now” – or, maybe better wording, I don’t see anything that sounds like an acute injury that would have changed/worsened my symptoms. The spine surgeon did ask me several questions about my balance (yes, I’ve been having issues with balance) and he said a lot of “hmmmm” on exam, mostly pertaining to weakness of various muscle groups and I think my DTRs are now hyporeflexive (versus the hyperreflexia I had in June when I was in the hospital). All in all, I’m still wondering—what could I have possibly done to my neck to cause my current symptoms—any clues from the reports I cited above?

Thanks so much!

Pam

[Donald Corenman, MD, DC]

#9550

There is much information the decipher so forgive me if I miss some points from topics you raise. I will deal with the spine topics as I am not a vascular surgeon.

The CT report seems to be read with a leaning toward the vascular anatomy. There is some incomplete information regarding degenerative changes in the discs of the neck but no specific reading regarding canal diameter or specific areas of foraminal stenosis.

“What is a hemicord”? This is not a specific clinical term. This literally means one half a cord and does not refer to any specific structures.

“Extraforaminal nerve root sleeve diverticulum” are Tarlov cysts. These are dural outpouchings and generally not pain generators.

You do have multilevel foraminal stenosis on the myelogram report. These narrowings can compress the exiting nerve roots and create radiculopathy (pain, numbness and possible weakness) of the compressed nerves. Some of your arm pain and shoulder dysfunction can be a result of this.

“3 mm of anterolisthesis of C2 on C3 that reduces on extension and neutral views” is generally a chronic finding called a degenerative spondylolisthesis (see website). This commonly occurs due to wearing of the facet joints.

Degenerative changes are very common in the general population and take years to develop. Most individuals with these changes will never know that they exist. However, these degenerative changes will progress in some patients. Eventually, the foramen will narrow enough or a particular action (injury or otherwise) will injure the nerve root enough to cause swelling of the root.

The nerve no longer fits into the foramen and chronic pain develops with motion.

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.

[PamC]

#9552

Thank you so much, Dr. Corenman!

Initially, back in June, they (the hospitalist team) seemed most concerned with vascular issues. I had occlusive blood clot in several veins (with much axillary and supraclavicular swelling) post pacemaker placement.

I could not get a therapeutic INR on warfarin so was switched from heparin drip in the hospital to Xarelto. Voila. The blood clot dissolved fairly quickly (as least the visible/palpable cords, jugular and axillary seemed to melt away). I did, however, have ongoing issues with shoulder/arm pain and weakness and some issues with my left leg (e.g., spasticity, weakness). The neurologist who consulted during my hospital stay said my symptoms made no sense to him and pretty much sent me on my way, even suggested a possible psychogenic basis to my symptoms (which is totally hilarious if you knew me; I’m more often accused of being too laid back and stoic for my own good).

In any event, when my symptoms persisted, I sought second opinion(s). I’m told I have a small diameter spinal canal with compression on the cord at multiple levels. If I understand the brief feedback from the spine surgeon, the compression of my cord is increased by certain movements (in certain ranges of motion). As a patient, I’m trying not to ask stupid questions, but am trying to understand how one neurologist would shrug his shoulders and a second one would send me ASAP to a spine surgeon, the latter of whom is basically recommending extensive surgery (almost sounds like cervical reconstruction with combined anterior/posterior approach and intervention at multiple levels…lots of decompression and fusion).

In the hospital in June, I had several days of abnormal neuro exam (upgoing toe on the left, significant ankle clonus and knee clonus, hyperreflexia). When I saw the spine surgeon last week, I had diminished/absent DTRs at the knees. So, I get the impression that my situation is fluid. I’m happy now that I’m followed by a neurologist and orthopedic spine surgeon who I like a lot and trust. Maybe I should just ask for a copy of my clinic note. My diagnosis had been “active C5 radiculopathy” and “left ulnar neuropathy” and I think the spine surgeon takced on “cervical myelopathy.”

What constitutes cervical instability? When you use that term, what do you mean? Abnormal motion of the vertebral segments?

Again, thank you so much. There *is* a lot of information to decipher. In March of this year, I’d have claimed to be an amazingly healthy adult. Events of the past few months are a lot of “take in” and make sense of.

[Donald Corenman, MD, DC]

#9555

Instability is generally defined as abnormal motion of 3mm or greater on flexion/extension films. Understand that this motion may be painful or put the cord at some risk but may also be totally asymptomatic and nothing to worry about. It depends upon many other circumstances.

If you do have cord compression, this can be an issue. The spinal canal narrows with extension (bending the head backwards). A forceful fall onto your face or forehead can cause a pinching of the spinal cord and a possible central cord injury (see website).

Chronic compression of the cord can produce myelopathy, the painless dysfunction of the cord. Myelopathy can cause imbalance, loss of fine motor skills, bowel and bladder dysfunction, strange paresthesias in the arms and legs and sharp electrical pains in the arms or spine. These symptoms are accompanied by long tract signs (hyperreflexia, clonus, Hoffman’s sign, Babinski’s sign and difficulty with quick motions-positive triangle test and Rhomberg’s test).

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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