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  • Queen V
    Member
    Post count: 4

    Dear Dr. Corenman,

    Thank you for the lifeline you’ve thrown to so many of us. You are a rare and generous man.

    Let me start by stating that I am unbelievably stoic. I have osteoarthritis and DDD in my cervical and lumbar spine. The OA and DDD go back at least three generations. Thoracic spine has not been studied but I do have symptoms in that area. I started having central neck pain with radiating pain down my shoulder and right arm when I was 23 years old (I believe it began even earlier than that). A neurologist ordered an x-ray and told me I had a narrowed disc space and he could feel the spasms in my neck — he prescribed traction/heat at home. I am now 55 years old and things have progressed to the point that I am quite disabled and I must govern every single move I make. I’m cautious about both head and lower back movements. I spend most days in a recliner because any type of movement — standing, using my arms or walking causes so much pain that I sometimes feel I’d rather die than feel that level of pain. No, I am not suicidal. I sleep in a recliner because both sides of my upper/outer thighs are exquisitely painful to lie on. I’m unable to lie on either side and my internist believes I may have bursitis on both sides.

    I’ve had x-rays and MRIs a several times along the way, but I was never referred to a neurosurgeon. It’s a very long story, but I keep falling through every crack there is. I’ve tried everything: epidural steroid injections, chiropractics, traction, PT, TENS unit, exercise, yoga (impossible) etc. You name it, I’ve tried it. I am currently taking Hydrocodone, Baclofen, Cymbalta, Neurontin and Amitriptyline; but they do little for the pain. I am unable to take oral non-narcotic anti-inflammatory meds because I have Barrett’s Esophagus.

    I can walk for a little bit, but have to rest because my legs feel very heavy or weighted down. My fine motor skills are very poor and my arms/hands and fingers feel weak. I used to type 135 WPM, but now I can’t do more than a few minutes on the computer because my hands/fingers don’t cooperate with me and it causes severe pain in my neck/shoulder/arm. My movements are very uncoordinated and clumsy. I’m unable to hold a book to read or hold my cell phone to my ear for very long due to weakness in my right arm. Writing can be very difficult and my handwriting changes appearance depending on the level of weakness I’m experiencing; putting on jewelry and buttoning clothing are all quite difficult if not impossible. I used to make jewelry but had to give it up due to poor motor skills and weakness. I have shooting nerve pains that go down my right shoulder area and arm — it feels like lightning and my arms feel heavy and awkward. Sometimes I wake up at night and both arms and hands are numb and dead. I walk like I’m drunk and list to the right. I cannot stand in place with my eyes closed without falling over. Getting up at night is awful as I walk into doors, fall down etc. in low light or darkness. I’m unable to tell where I am in time/space. I can’t climb stairs very well. I sometimes must push off of the insides of my feet in wobbly fashion to get up steps. I’ve tried riding on the back of my husband’s motorcycle a couple of times and when I get off the bike I’m unable to lift my legs to step up on a curb or steps. Given enough time I’ll come out of it.

    My neck is exquisitely painful. Leaning over to try and weed my flower bed for 5 minutes and I’m immobilized from the neck, arm and back pain. It almost feels like a water balloon is expanding from my neck up into my head. I wish I understood why leaning over that way is the worst precipitating event. But sneezing, coughing or turning my head; also leaning over to rinse my mouth after brushing my teeth can cause shooting pains in my neck and down my arm. When that happens I’m unable to turn my head at all. I have had episodes when I’m unable to hold my own head up and must rely on a cervical collar. The symptoms can last days to months and they are very long “attacks.” One day I turned my head too quickly in the shower and instantly felt very weak all over. I knew I was in big trouble so I left the shower running, got down on the floor onto my back and just laid there as I felt paralysis wash over me. I couldn’t move my head or my arms for about a half hour. I was terrified, but little by little enough strength came back for me to get myself to bed.

    My lower back hurts all of the time. It worsens when I stand too long or lean over for a few seconds. Shopping is out of the question unless I’m leaning on a shopping cart. Still, even that is very limited and I know I have a short amount of time to get what I need and get out. I get back relief by leaning over as far as I can while sitting. I get neck relief by letting my head dangle over between my legs, or by having my husband pull on my head gently while I lie on my back on the floor. Family/friends comment about my frequent position changes. I have so much lower back/upper-outer thigh pain that I must change positions very frequently.

    Whatever the problem is, it seems episodic? even though I am in almost constant pain. The physicians I’ve seen (GPs and internists) don’t always elicit the weakness and deficits I describe. They do note that I don’t have reflexes in my knees and ankles, but once in a while reflexes are very brisk. They have noted slight weakness in my arms and hands a few times, but seem to feel this is insignificant. The degree of weakness varies in response to whatever physical activities I’ve done in a day, however meager. I have an orthopedic appointment at the end of September but that seems so far away.

    Most recently I’m having involuntary muscle jerks and fasciculations (seen, felt and documented in the ER). I do not have ALS — the muscle jerks and fasciculations are clearly my body’s response to being on my feet and/or using my arms. I also have tremors and shakiness after using limbs. My rear end is numb and I have experienced urinary and fecal incontinence. I have pain down the backs on my thighs. I also get pain on the side of my calf that radiates around slightly and down the front. I get painful muscle cramps? in my ribcage and through my back, always at the same level. I also get frequent and very painful muscle cramps and contortionist-like positions in the last three toes on my left foot. My back feels best if I lean over and rest while doing dishes, if I’m on my feet and conversing with someone I lean over on a counter or ask if we can go sit down. On the rare occasions that I feel well enough to go shopping I feel best leaning over a shopping cart. On one occasion I turned my head quickly and had to lie down very quickly because severe weakness set in. Once I was on my back I couldn’t move my head or arms. I’ve had long-term changes in sensation with numbness and tingling in hands and feet. Again, I am extremely stoic and I think maybe that affects the doctors’ perception of the amount of pain I am in.

    I really did slip through the cracks or several docs dropped the ball because I’ve had three MRIs but have not been referred to neurology.

    ______
    Here is my 2003 MRI:
    An MRI/MRA of the neck revealed degenerative disc disease with spuring at C2-3, C3-4, and C5-6 with narrowing of the cervical spine canal. The spinal canal is effaced, but the cord itself is intact with no T2 signal abnormalities. There is minimal narrowing of the cervical foramen at several levels, but nothing that appears to efface transversing cervical roots.

    EMG
    A few scattered motor unit potential changes in C7 innervated muscles on the left, sugestive of an old radiculopathy.

    Peroneal nerve motor responses were low and conduction slightly low. The changes are suggestive of a peripheral neuropathy.

    Median sensory conduction velocity was slightly slowed. The needle examination abnormalities were slightly large motor units in the left triceps and low cervical paraspinal muscles.

    Evidence of distal postganglionic sudomotor and minimal cardiovagal/cardiovascular adrenergic impairment.

    QSART responses were reduced at the foot site (-99) and normal for other sites.

    ______
    2004 MRI
    The C3-4 level demonstrates uncovertebral spurring on the left with assymetric narrowing of the left C3-4 neural foramen. No cord impingement at this level. The C4-5 level demonstrates spondylosis with osteophyte disc complex eccentric extending to the left which does closely approximate the cervical cord without cord impingement. The C5-6 level does demonstrate spondylosis with osteophyte disc complex which does closely approximate the cervical cord at this level with minimal cord deformity. The C6-7 level demonstrates osteophyte disc complex which does extend to the proximal left C6-7 neural foramen.

    IMPRESSION: Multilevel cervical spondylosis.

    2) Osteophyte disc complex does closely approximate the cervical cord at the C5-6 level with minimal spinal cord deformity.
    3) Osteophyte disc complex is also noted at th C6-7 level extending to the left and the C4-5 level extending to the left.

    It looks like the cervical spine is visualized and there is contrast for an arterial study. In looking at the study, I think there is cervical cord impingement with the right signal in the cord itself suggestive of myelopathy from cord impingement.

    I also had Tech-99m scan or nuclear bone study? There was a focus of mildly increased activity in the left side of the L4 vertebral body. Also linear increased uptake in the right anterior iliac crest area. There is asymmetry between the right and left side. There is a question of osteopenia. Hip joints show early degenerative changes with acetabular sclerosis. There are some benign-appearing calcifications within the pelvis. Slight irregularity to the pubic symphysis consistent with chronic osteitis pubis. I have a stress fracture in the L4 vertebral body and a herniated disc at that level. It was initially thought to be metastasis from my breast cancer, but that was eventually ruled out.

    The neurologist lost the MRI, bone scan and radiology reports so there was no follow-up again. I do have a history of high parathyroid hormone but no parathyroid disease. Secondary hyperparathyroidism? Sorry, I can’t remember. I did copy some of my medical records to my computer before they disappeared.
    ______
    2012 MRI

    Notes Recorded by Christopher, MD on 6/14/2012 at 7:35 AM
    You do have some impingement especially in your cervical spine. I’ll await the opinion of neurology on whether or not this could be causing your symptoms.

    Result Narrative

    Indication: Upper and lower reticular and spastic symptoms

    Exam: Cervical and upper thoracic spine MRI without IV contrast. This
    study extends from the clivus to the T4 vertebral body. The study
    includes sagittal T1, STIR, T2 RESTORE and T2 3D SPACE volumetric
    images; axial T2 and MPR images; coronal MPR and bilateral oblique
    sagittal MPR images through the foramina; diffusion weighted images
    and corresponding ADC map.

    Comparison: None

    Findings: The craniovertebral junction and overall alignment are
    normal. The signal intensity in the bone marrow is normal on
    T1-weighted images when compared with intervertebral disc signal.

    C2-C3: There is no canal stenosis or foraminal narrowing.
    C3-C4: There is a small disc osteophyte complex causing mild
    effacement of the ventral thecal sac. There are bilateral uncinate
    spurs causing moderate left and severe right neural foraminal
    narrowing.
    C4-C5: There is a small disc osteophyte complex with a left
    paracentral component causing mild to moderate canal stenosis and mild
    effacement of the leftward aspect of the cord. There are bilateral
    uncinate spurs causing moderate left and severe right foraminal
    narrowing.
    C5-C6: There is a disc osteophyte complex causing moderate canal
    narrowing without increased cord signal. There are bilateral uncinate
    spurs causing moderate left and severe right foraminal narrowing.
    C6-C7: There is no canal stenosis or foraminal narrowing.

    A limited evaluation of the upper thoracic spine shows no evidence of
    fracture or dislocation involving the visualized levels. Disks are
    normal.

    Result Impression
    Impression:
    1. Moderate and severe degenerative changes in cervical spine as
    described above worse at the C5-C6 canal and multiple right-sided
    neural foramina. Cord signal is normal.
    2. Normal upper thoracic spine MRI

    Result Narrative
    Indication: Upper and lower extremity radicular and spastic symptoms.

    Technique: Lumbar spine MRI without contrast. The following images
    were obtained: Sagittal T1 and T2 images; diffusion weighted images
    and corresponding ADC map; axial T1 and T2 images which extend from
    the L1-L2 intervertebral disc through the L5-S1 disc.

    Comparison: None

    Findings: Alignment is normal . The signal intensity in the bone
    marrow is normal on T1-weighted images when compared with
    intervertebral disc signal. The conus medullaris is in normal
    position and terminates at the L1 level. Spinal cord signal is
    within normal limits at all levels.

    L1-L2: There is no canal stenosis or neural foraminal narrowing.
    L2-L3: There is no canal stenosis or neural foraminal narrowing.
    L3-L4: There is no canal stenosis or neural foraminal narrowing.
    L4-L5: There is a diffuse disc bulge with a larger right foraminal
    component as well as mild buckling of ligamentum flavum and facet
    arthropathy causing moderate right lateral recess stenosis and
    foraminal narrowing.
    L5-S1: There is no canal stenosis or neural foraminal narrowing.

    Result Impression
    Impression:
    1. Moderate degenerative changes at the right L4-L5 lateral recess and
    foramen.

    I don’t understand why there are so many discrepancies from MRI to MRI. Will you please help me understand what all of this means and how it pertains to my symptoms? I am particularly interested in my 2006 MRI.

    With much gratitude,
    Queen V

    Donald Corenman, MD, DC
    Moderator
    Post count: 8409

    MRIs performed on different machines can yield different views. If any of the MRIs were on an “open” scanner, these images will be poor and either over or underestimate the pathology. Always try to obtain scans on a “stronger” machine (measured by tesla strength), even if you have to have a sedative to complete the scan. 1.5 tesla is the minimum strength but 3.0 is better. The “open machines” rate as 0.3 tesla strength.

    Radiologists also “read” scans differently as some values are open to interpretation. “Moderate” narrowing to some would be “severe” to others.

    You have degenerative changes throughout your spine. This is not unexpected as the spine unfortunately does not stay pristine throughout our life. Back and or neck pain can occur from degenerative changes of the discs and arm and or leg pain occurs from compression of the nerves in the exit zone (foramen) from bone spurs.

    You might have central cord compression in your neck. The presence of central compression is unclear (as you note) as some MRIs note this finding and other do not. Check the chapter for myelopathy on the website to see if you have symptoms of this disorder.

    I’m sure this sounds strange to you but some patients develop hypersensitivity to pain and the pain becomes magnified. This can occur with depression or the onset of fibromyalgia although these disorders do not have to be present for the presence of pain hypersensitivity.

    You need a good spine surgeon to take a long look at you and probably a pain specialist also.

    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.
    Queen V
    Member
    Post count: 4

    Thank you so very much. I didn’t realize there was a difference in MRI machines. Fibromyalgia has been ruled out many times, but I know some people become more sensitive to pain than others. I don’t think that describes me as I have had two surgeries and did not require pain medication afterward. Perhaps I’m depressed and don’t realize it. At any rate, I have an appointment with a pain specialist and will be seeing a spine specialist.

    With much gratitude,
    V

    Donald Corenman, MD, DC
    Moderator
    Post count: 8409

    There are four basic questions to determine if reactive depression is present.

    Are you lethargic (tired most of the time)?

    Do you sleep well or do you have trouble getting to sleep or wake up frequently?

    Are you irritable (do you cry easily over nothing or snap at people)?

    Do you have anhedonia (inability to look forward to the next enjoyable activity)?

    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.
    Queen V
    Member
    Post count: 4

    Are you lethargic (tired most of the time)?
    • Yes. I have SLE, sensory and motor neuropathy and am on O2 for severe lung disease.

    Do you sleep well or do you have trouble getting to sleep or wake up frequently?
    • Usually no trouble getting to sleep, but wake up due CPAP mask malfunction and/or back pain.

    Are you irritable (do you cry easily over nothing or snap at people)?
    • No

    Do you have anhedonia (inability to look forward to the next enjoyable activity)?
    • Sometimes

    Donald Corenman, MD, DC
    Moderator
    Post count: 8409

    With the diagnosis of restrictive lung disease and peripheral neuropathy from SLE (Systemic Lupus Erythematosus), your pain generation could be from many sources. Many patients with SLE also suffer from depression. You should ask your rheumatologist or primary care physician if you might be a candidate for an SSRI.

    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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