[ksable]

#20590

Hi,

I am an emergency medicine physician who converted to administration 3 years ago and now run a large academic medical center. I share my story in the hopes of finding some solution to my pain. Here is my story:

2001 – spontaneous C5-6 herniated disc with moderate to severe right lateral recess and neural foraminal stenosis. There was significant mass effect on the exiting C6 nerve root. I had the typical RUE weakness and pain from neck to biceps region. I saw a neurosurgeon and two orthopedic surgeons and elected to manage conservatively. For the most part, my symptoms improved, my weakness improved, and I was mostly much better. Over the years I have dealt with intermittent neck pain but mostly manageable and it largely did not affect my quality of life.

2010 – I had worsening pain but still mostly manageable. I had a repeat MRI which showed a “right sided C5-6 disk/osteophyte complex with probable compression of the right C6 nerve root.” Essentially nothing new compared to 2001. Again, I improved and was at least back to my baseline.

2015 – I was doing a lot of running (5 miles per day on weekends) and in April began to have acute NEW type pain. This pain was mostly axial neck pain, L worse than R, and again no neuropathy or other radicular symptoms. I had a repeat MRI in April which showed no interval changes with regard to C5-6. New however was mention of C2-C3, “there is mild left facet hypertrophy, new since previous examination. There is resultant mild left neural foraminal narrowing. The right neural foramen and central canal are patent.”

This new pain was dull, aching, constant, worse with sitting, and mildly relieved with NSAIDs and heating pad. Also NEW is sub-occipital pain also probably worse L vs. R. I am definitely one with forward head posture (FHP) as I spend hours on a computer daily for many years now. I did massage and PT without much improvement. I had done acupuncture in 2010 but not again now. Also new and most disturbing was painful “clicking”, again worse when turning L vs. R.

After several consultations, I elected to undergo ACDF at the end of August (now 8 weeks ago). I considered TDR but given the axial nature of the pain, we all felt the fusion would be better to reduce mobility if symptoms were related to uncovertebral or facet joint pathology.

I went back to work 2 weeks after surgery but symptoms largely remained. Pain is constant, debilitating, and not improved with daily tramadol, etc. I have begun PT again 3x/week. My follow up plain films a week ago demonstrated “interval anterior cervical fusion at C5-6 without evidence of hardware complications.” My surgeon (and I) see good bone-on-bone on the xray. Also shown is “grade 1 anterolisthesis of C2 on C3 measuring 2mm that reduces with extension but does not worsen with flexion, suggesting mild dynamic instability.”

Finally, thinking this could be related to C2-3 facet changes (suboccipital pain), I saw my pain management friend (anesthesiologist) who did medial branch block/facet block b/l through most of the cervical spine. Given that I still have pain 2 weeks later, we discussed a myofascial component and will likely consider trigger point injections next. We also discussed possible atlanto-occipital or atlanto-axial blocks in order to better identify the pain generator.

At this point, I am looking for any feedback or suggestions for how best to proceed. Before April, I was managing the symptoms relatively well but since April I am in agony daily. While I certainly had the C5-6 HNP for 14 years, I am not sure that was related to my current symptoms and therefore the surgery in August may have been irrelevant or even unnecessary but that is done now. Is my dull aching axial neck pain along with suboccipital pain and clicking due to facet joint disease, even though it is not showing on MRI? Would a functional (vs. static) MRI or CT help better show what exactly is “rubbing” and causing all of this clicking? Or could this simply be normal recovery given my anatomy has been changed after 14 years of living in a different position?

Thank you in advance for any help!

[Donald Corenman, MD, DC]

#20593

I hope the new insurance company policies and governmental rules do not drive you crazy as an administrator.

The initial disc herniation back in 2001 can set the stage for further degeneration of the disc and foramen. The disc herniation “pulls off” the insertion of annulus and creates tension on the sharpey’s fibers that insert into the bone. This tension (called an enthesopathy) creates bone spurs and bony foraminal stenosis in some cases.

The herniation can also start a “degenerative cascade” of disc degeneration. For reasons that are still being determined. The nucleus “dries out” and disappears. The hyaline cartilage endplates then fragment and erode away. Bone on bone endplate opposition occurs and this is painful especially with impact. This is probably what occurred to your C5-6 disc.

The ACDF fusion is probably the correct surgery as if this disc level collapsed, an artificial disc replacement is not the recommended procedure.

I will assume that this level fused as even if it didn’t, the original pain should initially resolve for 3-5 months until the pseudoarthrosis announces itself. No pain relief to me means that this might not have been the original pain generator.

The “grade 1 anterolisthesis of C2 on C3 measuring 2mm that reduces with extension but does not worsen with flexion, suggesting mild dynamic instability” could be the pain generator but this level will cause base of the skull pain, headaches and upper neck pain. If pain is lower in your neck and radiates into the trapezius muscles, I would suspect the pain generator to be lower in the neck. Identification of the location of symptoms and activity that aggravates the pain would be helpful.

Pain generators are identified by the lidocaine or marcaine component which would give only 2-4 hour relief. Do not look for long term relief as a “positive diagnostic block” may or may not confer long term relief. This is the same as a steroid injection in the buttocks yielding knee pain relief. Obviously, the injection does not affect the knee directly but the “systemic steroid effect” reduces inflammation throughout the body. You are looking for relief only in the first 2-3 hours for a diagnostic block. See Pain diary on the website to understand how to keep track of the diagnostic position of this block.

The absolute best functional imaging for the cervical spine are X-rays with flexion/extension views coupled with an MRI. A CT scan can be helpful especially with a prior fusion to determine fusion mass and look also at the bony component of the facet arthrosis.

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.

[ksable]

#20598

Hi,

First, thank you so much for your quick response. Being on the administrative side has been very interesting! But with all the changes happening in healthcare today, it’s actually a great time to be doing all of this work. Aligning with physicians, hospital mergers, new payer strategies, etc. are all very exciting!

Interestingly, yesterday was the first day since April when my new acute pain began, that I actually felt some relief. I have no idea why, but I’ll take it! 9 days earlier I had the medial branch and facet blocks, so unless it would take 9 days for the steroid to kick in, I can’t attribute any relief to those injections. Today, however I am very sore again. I am supposed to see my pain doctor tomorrow for consideration of trigger point injections as he thinks there could be a myofascial component as well?

Regarding C2-3, most of my symptoms have been suboccipital pain to the base of my skull. Plus L upper neck pain more so than lower. This is why I thought this could be the pain generator. I have no headaches however. I therefore expected that the facet blocks would have had a somewhat immediate effect, but I am not sure I felt any better after.

So, I had the plain films which I mentioned. I suppose I’ll follow up with an MRI or CT next? When would you recommend? And with all the ‘clicking’ with movement (mostly to the L side) are there any dynamic studies I can/should have that might be able to identify what is actually articulating/clicking with movement?

Being in chronic pain since April has been truly debilitating. I certainly hope I can find some answers, and as importantly some relief, sooner rather than later.

Thank you again for your time and help.

[Donald Corenman, MD, DC]

#20601

If you have had an ACDF with failure to relieve symptoms, I would obtain, a CT scan, an MRI without gadolinium and X-rays including flexion/extension. You need the “full court press”

Facet pain does not have to produce headaches (greater or lesser occipital neuralgia) so no headache symptoms do not rule out facet-mediated suboccipital pain.

If the injectionist used Celestone and not Depomedrol as the steroid, late relief is not too uncommon as Celestone is in precipitate and eludes out sometimes weeks later. If it was Depomedrol, this is already in solution (and more commonly used for cervical injections) so late-onset relief is rare.

Clicking is most commonly associated with facet disease but I have seen two cases of degenerative discs (out of hundreds) that cause painful clicking. Painful clicking is associated with a cervical degenerative spondylolisthesis (your 2-3 level).

For a block to be positive diagnostically, you must exhibit the symptoms to some severity (5 or greater on a 0-10 VAS) prior to the injection. The injection then must drop the pain by at least 50% (and hopefully much more) the first three hours. During the three hour diagnostic window, it is helpful to try and recreate the symptoms with activities that are know to incite symptoms. If these guidelines are followed and symptoms do not improve temporarily, the injected area is either not the pain generator or the injection was somehow ineffective (10% chance).

Some patients are much more tolerant of anesthetics (lidocaine or marcaine) as demonstrated by dental visits where the amount of injectable medication is either ineffective or significant higher quantities have to be used to obtain the anesthetic effect. These patients unfortunately cannot use diagnostic blocks to obtain information. If this anesthetic tolerance does not fit your profile, then don’t worry about this paragraph.

Let’s then assume that this block was performed accurately and did not yield diagnostic relief ruling out the facets. The pain generator still could be from disc or nerve root (radiculopathy). Careful determination of the foraminal diameter at this level (or the level below) to identify potential compression would then be the next step. If there is stenosis present, a diagnostic cervical selective nerve root block would be in order. A positive block could lead to an ACDF or a foraminotomy (a problem with degenerative facets). No foraminal stenosis would then lead to a possible cervical discogram, depending upon the appearance of the disc on X-ray and MRI.

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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