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Dr. Corenman,
I have a mess of a neck, but I will try to be succinct. My basic questions are (1) whether you have ever seen a shoulder freeze post-ACDF and (2) why I would still have osteophytes at the operative level.
I had ACDF at C6-C7 almost five months ago. I had a 6 mm partially calcified disc extrusion at C6-C7 resulting in severe central stenosis, as well as severe bilateral foraminal stenosis at C6-C7.
My situation was complicated by the fact that I have severe bilateral foraminal stenosis at every level of my cervical spine other than at C2-C3, where the foraminal stenosis is only left sided. I also have facet arthropathy noted at every level, except oddly the operative level. I also have 2 mm disc bulges at C3-C4 and C4-C5 and a 2-3 mm bulge at C5-C6.
Pre-surgery my symptoms were all left-sided, despite the fact that my foraminal stenosis is bilateral at all levels other than C2-C3 where it is only left-sided.
I had five pre-surgery consults — three from orthopedic surgeons and two from neurosurgeons. Two of the orthopedic surgeons and one of the neurosurgeons said to only fuse C6-C7 — that the other levels did not merit fusion. One orthopedic surgeon said fuse C5-C7 and the remaining doctor, a neurosurgeon, said fuse C5-C7 and put an artificial disc at C4-C5. My surgery was performed by a neurosurgeon who said we would fuse C6-C7 and we would later address the other levels with a foraminotomy. One of the orthopedic surgeons agreed with him. The other three consults told me there was nothing to be gained from a posterior approach. Anyway, that is all just by way of background.
I had my one level ACDF in January 2016 and did beautifully. I was back at work in 6 days and completely pain free for the first time in years.
However, about three months post-surgery, my left shoulder froze. I had no shoulder problems pre-surgery and, in fact, have done yoga for years and had great shoulder mobility where I could do very advanced yoga poses that required shoulder mobility.
After my left shoulder froze, my surgeon sent me for a consult with shoulder specialist orthopedic surgeon and he did a cortisone injection without fluoroscopy (which surprised me that there was no image guidance). The idea of the injection was to try to free up the shoulder so I could get back to my yoga practice and continue on my ACDF recovery. The injection was disastrous and I’m a little concerned the injection itself may have damaged the shoulder joint or torn something because immediately after the injection I began to feel pain in the joint, as well as burning on the inside of the upper arm and the shoulder became not just frozen, but very weak. This has continued in the six weeks since I had the injection. In other words, the injection left me worse off.
Following the disastrous injection, I was then sent for both a shoulder and a cervical MRI.
At the non-operative levels, the cervical MRI was consistent with the pre-surgery one. At the operative level, the report said (1) there was no evidence that I wasn’t fusing, but that a CT would be better to assess the situation; and (2) “Both foramina are markedly stenotic. There is mild effacement of the cord by a broad-based osteophyte.” I was shocked by the latter comment because I thought that osteophytes had been removed during the ACDF, and in fact, my operative report indicates “The neural foramen were opened bilaterally with a #1 Microsect shaver and the disk space distracted.”
The left shoulder MRI indicated “a mild degree of capsulitis” (sure doesn’t feel mild to me), “a delaminating tear of the distal supraspinatus with fluid tracking along the musculotendinous junction of the supraspinatus with no evidence of retraction” and “Tear of the posterior labrum at the 7 o’clock – 8 o’clock position.”
Following the MRI, I went back to the shoulder orthopedic surgeon who said he thinks it is really my neck that is the problem, not my shoulder, and he doesn’t want to do rotator cuff surgery because if the shoulder symptoms are from my neck, rotator cuff surgery won’t help me. I’m planning to get a second opinion from another orthopedic surgeon specializing in shoulders.
So, as I said, my two questions are (1) why in the world do I have osteophytes at the operative level following surgery when they were supposedly removed during surgery (MRI done almost 4 months post-op) and (2) have you ever seen a shoulder freeze up post-ACDF?
My symptoms are pain in the left scapula, frozen left shoulder, pain in the outside upper left shoulder — feels like someone punched me there — and occasional shooting pains between the thumb and index finger (which I assume is from C5-C6 pathology and which I had pre-surgery). I do have some left-side neck pain although it is better than before my ACDF.
Sorry to be so long-winded, but my neck is a mess and I’m just mystified why I felt so good initially after my surgery and now feel awful and have developed shoulder pathology to boot.
One small correction. The feeling of being “punched” that I am now experiencing is in the left deltoid, not in the shoulder, although I did not have that punched sensation until after the disastrous shoulder injection (although of course it could just be co-incidence).
The one consult pre-surgery who wanted to put an artificial disc at C4-C5 and fuse C5-C7 told me I had a very serious issue at C4-C5 and that if I didn’t let him put an ADR at that level, my left arm would become useless. In fact, his words have become prophetic, because the arm post-surgery has become fairly useless. My current MRI at C4-C5 reads: “There is loss of disk height and disk signal with a small osteophyte bridging the disk space, contributing to severe bilateral neural foraminal stenosis left greater than right as a result of marked facet disease. The cord signal is normal.”
Frozen shoulder syndrome can occur from many different types of shoulder injuries and is more common in diabetics than others. I can tell you that I have not yet seen a frozen shoulder from a cervical radiculopathy but assume that nerve compression can cause this disorder. The exact cause of frozen shoulder or adhesive capsulitis is not known so why a radiculopathy should cause this condition is still a mystery.
It is somewhat common for some individuals to have multiple levels of foraminal stenosis but only have symptoms in one or two levels. This is due to the size of the nerve root that occupies this tunnel. When a root is injured, it swells (just like injuring a finger). The canal is already tight but with a swollen root, this structure is now compressed and inflamed. This makes the root symptomatic.
Why this root is painful but others are not is probably due to the micro-anatomy of the foramen. Since this anatomy cannot be specifically determined by MRI imaging (resolution of the images is only down to 1-2mm), the images “volume average” or estimate the actual diameter. That is, you can see problems but cannot magnify the image to look at small areas.
For severe foraminal stenosis, an ACDF is the best procedure to decompress the foramen. This procedure allows distraction of the disc space which makes more room just by this distraction and then allows the surgeon to remove the spurs (uncovertebral joint hypertrophy) from the front of the foramen-the spurs that are causing the most compression. The posterior foraminotomy is a reasonable procedure for some root compressions but does not address the anterior spur nor distracts the disc space to make more room for the nerve.
I think one problem is that the affected nerve (or nerves) were never elucidated by a selective nerve root block. This procedure can identify the root or roots that are involved in pain generation (“https://neckandback.com/treatments/epidural-injections-and-selective-nerve-root-blocks-diagnostic-and-therapeutic-neck/). Without identifying the levels that need to be operated on, the surgeon is speculating on which levels are pain generators. This is why you had so many different opinions as to which levels needed to be worked on. Obviously, the C6-7 level needs to be included due to the central stenosis (C6-C7….I had a 6 mm partially calcified disc extrusion at C6-C7 resulting in severe central stenosis, as well as severe bilateral foraminal stenosis at C6-C7).
Nonetheless, you did quite well after a one level fusion for three months before you developed frozen shoulder syndrome. Unfortunately, the shoulder injection aggravated the shoulder. I cannot tell you why. Also, why the shoulder would become weak after the injection makes no sense to me. What does the orthopedist state regarding the increased pain?
The changes at the C6-7 operated level were not as great as one would expect (“Both foramina are markedly stenotic. There is mild effacement of the cord by a broad-based osteophyte”). At least the central stenosis is better but why you should have continued foraminal stenosis after an ACDF (“markedly stenotic”) is unusual.
The C4-5 level certainly can cause shoulder pain as the C5 nerve Which originates from C4-5) services this area. I have some concern for an ADR (artificial disc replacement) at this level for two reasons. First, an artificial disc generally should not be placed in at a level with degenerative facets and if these facets are degenerative enough to cause nerve compression, placing an ADR at this level will not relieve the root compression since the disc is placed from the front of the neck and the compression is in the back of the neck. (“severe bilateral neural foraminal stenosis left greater than right as a result of marked facet disease”).
It is not predetermined that “your arm would have been useless” but I do have concern that C5 could be causing some of your symptoms. A selective nerve root block (SNRB) would be helpful to determine if this level is really causing pain. A good physical examination would also be indispensable for understanding what is going on.
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.Thank you for replying to my post Dr. Corenman. I wanted to update you and I had an additional question.
I ended up having shoulder surgery two weeks ago. The operative report noted “Adhesive capsulitis with chondral defect inferior glenoid, posteroinferior labrum tear and extensive subacromial bursitis, bursal side cuff, tendinosis and abrasion with an osteophytic spurring anteriorly, left shoulder.” The rotator cuff fraying was deemed too insignificant to stitch or anchor. The capsule was released through manipulation and they also did an arthroscopic labral debridement with chondroplasty of the glenoid, extensive bursectomy and limited acromioplasty.”
The surgery was successful in that I have more range of motion than before surgery, although I am still not 100% with hand behind the back and up the shoulder rotation. As part of the surgery, I received an interscalene block, which I understand blocks C4-C7. I have to say that for at least a week after surgery, my neck and scapula felt great, which I attribute to the effects of the block — I think even after the main effect wore off and my arm was no longer paralyzed, there was some residual effect. Now two weeks later, my neck and scapula pain is back, plus throbbing in my upper side arm, which had disappeared after surgery, is back.
So I guess I received a kind of nerve root block as part of my shoulder surgery, except it wasn’t selective because I believe it hit C4-C7. My question is if I now want to try a SNRB, given that I have problems really from C3-C7, do I somehow go for four separate blocks and how far apart are they spaced? I also have to add that I am reluctant to have a “therapeutic” block with steroid, as opposed to a diagnostic block with lidocaine only, because when I had a cortisone injection into my shoulder, I had a terrible reaction with a red burning face and the cortisone also ramped up my appetite, which caused me to gain weight. I was wondering how frequently you see cortisone flares and whether purely diagnostic blocks without cortisone are worth considering.
If you have reaction to steroid injection, the selective nerve root block could be only a numbing agent (Lidocaine or Marcaine) which would lead to a diagnosis without the potential of long term relief. You probably don’t need to block every level but with a good history and physical examination, suspicion of individual levels can narrow the levels necessary to test.
I have seen rare reactions to injectable steroid. It does occur but it is unusual. With a prior experience of complications with this injection, you probably have a higher chance of this complication recurring.
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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