Polyneuropathy from post-cervical decompression?

///Polyneuropathy from post-cervical decompression?
Polyneuropathy from post-cervical decompression?
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  • lcanning
    Participant
    Post count: 2

    Hi Dr. Corenman,

    Thank you for the wonderful forum! Been reading some other posts on here and wanted to ask about some things that I have been experiencing more and more since about 10 weeks post-op on my c5/c6 – c6/c7 decompression procedure (foraminotomy and laminotomy), which was done in order to address left arm and hand numbness / weakness that had been getting worse for about a year. I’m a 33 y/o male.

    I should start by saying that I was briefly up and walking around as directed the very next day after this surgery, and by day 4 post-op, had even taken a 20+ minute walk to a beach, though with usual pain, etc. Per my discharge instructions from the facility, we were advised to try to walk like this at least 10-15 minutes a day several times a day even the first week post op, but to try slightly longer walks from days 4-24, and then so on.

    Anyhow, for the ensuing 6-7 weeks post-op, overall I had what I believed and still believe to be the usual recovery symptoms for such a surgery: Transient shooting pains, transient numbness, neck weak from wearing a brace, etc. While I was on my back a great deal during this time, I still worked on my laptop, cell phone, etc. and was able to walk no problem at all. I even walked my usual half-mile loop to and from the grocery store and tried going back to the office part time for a week and a half at about week 8. However, during this time I noticed that my left leg especially was becoming numb and weak to varying degrees, which I had chalked up to a separate mild disc bulge in l4/l5 that I later found out was not serious at all. Which brings me back to my neck.

    At about week 10, I noticed that my neck surgery site began to regularly have this “weak” feeling as if the site was not stable. This unsteady sensation had first presented very infrequently around weeks 8-9, but it was never prolonged. During that time I also experienced what I believe was a nerve compression incident at the other end of my spine, where I began having weakness in my legs focused on the groin area about an hour after this straining episode in the bathroom. Basically, it felt like an extreme squeeze of all of my nerves in my sacral plexus area which lasted about 1-2 seconds – and then within one hour of trying to “walk it off”, my legs started feeling unstable most notably in the groin, and so I was in the ER having a lumbar MRI, which short of a note about l3/l4 being slightly bulged, was unremarkable. Imagine my shock! No cauda equina syndrome.

    Fast forward to week 10, and after some electric shocks in my legs in the couple of days after that incident, my legs felt normal again. But by week 10, my numbness in my sacral plexus returned while walking through the grocery store. The day after that incident, I was consistently having trouble walking and keeping my balance due to leg numbness. Electric shocks down my spine also started to occur if I overdid the walking / standing, and it seems to originate from my neck surgery site.

    I am now entering week 13 post-op, and after being in and out of ERs and going back to my original surgeon who is out of town from me, I have had the opportunity to do all fresh MRIs of my entire spine, and while it is not perfect, I am being told by the surgeon who operated on me that despite the radiologist notations that at c5/c6 I have “slight indent” of the “cord”, and c6/c7 touching of cord, he noted that all of these symptoms are not the result of his surgery or my current level of compression. In fact, he maintains that I do not have any meaningful cord compression! At his request during this consult this past week, I had an EMG done of my arms and legs which showed some areas where I only had 4/5 rated strength, loss of sensory at L3/L4 nerve roots, DT +1 of my ankles, very mild clonus, and signs of nerve root impingement at c3/c4 above where I was operated on. Overall impression was that I had “subtle” signs of early onset polyneuropathy, cause unknown. Well, alright then!

    The frequency and severity of the electric shocks appears to be subsiding now, but I still am having trouble sleeping without waking up numb, or having my whole body having some paresthesia if I sit or lay too long. I have always been a side sleeper but that is now out of the question, if I do not sleep on my back I will likely get twitches or electric shock type sensations, which I actually now realize I was starting to get years ago on occasion before I even knew I had a disc herniation.

    So while I wait to see a neurologist about all of this, I am forcing myself to walk around the house more now as opposed to sudden use of cains, office chairs with wheels, etc., and while I have not fallen down, I am a little concerned that this has even happened at all.

    Is it not possible that I am just having arachnoiditis / myelopathy from this surgery? I had asked my surgeon about myelopathy even before I had the surgery because of the nature of the cord compression that I definitely had before he decompressed me. He indicated that as of now, that my CSF was still “surrounding” my surgical site sufficiently, and that it was healing well, but even I can tell that my CSF at the area is razor-thin. To be fair, all of the ER doctors who saw me over the past couple of weeks who do not know this surgeon had concurred that another surgery was not needed, and to try therapy, etc.

    I tried a few sessions of PT and while I can do the exercises that they give me, I can barely move my limbs for 2-3 hours afterwards due to the irritation of the neck site. Also, moving my feet / cracking my big toe knuckle sometimes is enough to set off my neck irritation. So I question whether PT is appropriate at this time or at all for me.

    Bottom line, I am torn between whether I am facing delayed-onset arachnoiditis / myelopathy from this surgery or just some bumps in the road from a multi-level neck surgery that may need more than 12-13 weeks to “calm down”.

    The electric shocks seem to be subsiding now, and when they happen they are less strong, though I don’t know if that’s because they are truly subsiding, or because I’ve already got damage from the first several causing things to get worse and I just don’t feel them as strongly now. Does it even work that way with those shocks? I am encouraged that through all of this, that my MRI doesn’t seem to show any demyelination of my cord itself, but this is all very upsetting and confusing to someone who feels like they took a step back 10 weeks after what was until then by all appearances, a routine surgery.

    Thanks for your time and for reading my story!

    Sincerely,

    Lucas
    Miami, FL

    Dr. Corenman
    Moderator
    Post count: 6328

    Your symptoms could result from a number of disorders. The first disorder I would think of is of the cervical spine as the source. The posterior laminotomy technique is not unknown for cord retraction injury and your symptoms of “electric shocks” (l’hermittes syndrome), ankle clonus (a sign of hyperreflexia), imbalance and “my whole body having some paresthesia” all lead to a suggested diagnosis of myelopathy, either current or cord injury from retraction. Is there any evidence of cord signal change and did you have gadolinium with your MRI post-surgery?

    Your report of “despite the radiologist notations that at c5/c6 I have “slight indent” of the “cord”, and c6/c7 touching of cord, he noted that all of these symptoms are not the result of his surgery or my current level of compression. In fact, he maintains that I do not have any meaningful cord compression” may be wishful thinking on your surgeon’s part. Especially since the posterior foraminotomy makes out about half the facet and this can lead to instability. Instability would only be recognized by flexion/extension X-rays as the MRI is performed with you lying down-taking gravity and motion out of the equation.

    Your feeling of instability after a posterior foraminotomy is not too atypical for the first 1-2 weeks as muscle has to be moved/detached but after scar forms (at about three weeks), the neck should feel stable. Continued feeling of instability also reenforces the possibility of a true mechanical instability.

    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.
    If this forum has helped you, please let Dr. Corenman know!

    lcanning
    Participant
    Post count: 2

    Thank you Dr. Corenman! I was not aware of the “retraction” injury possibility, I had not previously heard of. While I did not have contrast done with gadolinium in any post-op MRIs, I was given the following as part of the radiologist impressions as a part of 2 follow-up cervical MRIs done post-op, and also a CT scan that I had done when I first felt like something was becoming unstable. I put the snippets of the CT and 2 MRI’s at the bottom of this post.

    One of the MRI’s seems to think there is no cord signal abnormality, one doesn’t weigh in on that aspect at all, and the CT scan seems to think everything is stable in terms of the vertebrae, but maybe contrast is needed to confirm signal issue? That said, the snippets below of those exams are a little confusing to me given how I still feel at the site where the surgery was done. If I roll over too fast in bed or my neck gets pressed on there, sometimes I get a rude awakening in terms of those shocks or a numb feeling for an instant in a leg, arm, etc.

    My surgeon also did a “just in case” MRI a few days ago on 07 FEB 2018 and basically said, nothing has changed since your last MRI of your neck on 23 JAN. He also did some x-rays, including flexion position x-rays, but they were never even discussed, so I’m hoping that means there’s nothing there of note. Hence the polyneuropathy conclusion on his part and his sending me off.

    With that. I am in a position now where I feel like I need to try to keep walking as much as possible rather than continue to lay dormant and afraid to walk around at all (which is what I’ve mostly been doing the past couple of weeks), but at the same time I do not want to hurt myself. To that end, neither my surgeon nor any physicians in the ER here have told me that I am in any immediate danger of serious injury from walking around the house as long as I avoid falling, etc. But it is certainly unsettling to have some of the symptoms I’ve been having the past 2-3 weeks and wondering what I should be doing, and if it is the right thing to stay out of the hospital, though I’ve taken myself to it about 6 times in the past 2 weeks out of a maybe too-healthy abundance of caution.

    I am still relatively young and just want to stay on top of these symptoms before they become long term or permanent. I know time is of the essence with a lot of these issues especially if it is myelopathy, arachnoiditis, etc. I still test negative for Hoffman’s and Babinski’s and my gait is able to be totally normal as long as the swelling in my neck is contained before I try to get up. The problem I notice is that if I stand or walk long enough during the past couple of weeks, I feel what I would describe as a pressure / crushing sensation near the site of my neck surgery, and from that moment on, I seem to have about 10 seconds or less to sit down or I’m probably going to have an adverse event (fortunately, it hasn’t ever gotten to that point because I always seem to find a spot to get to by then). That said, even when sitting back down after one of those flare ups, proceeding to dragging my foot slowly across the floor can make my neck surgery site tingle. Or, lifting that same foot even an inch or two off of the floor during one of these flare ups causes pressure / tingling in the neck site as well. It’s bizarre.

    While I admittedly haven’t done much rehab to strengthen the area around my neck surgery to this point, I’m not sure if rehab can offset whatever that sensation is, though I find it interesting that it never happened the first 8 weeks post-op. Is this the “retraction” injury possibility?

    Every day is getting sort of scary, but every time I go to the ER here locally, I get sent home and told I have no imminent spinal emergency on my hands. That’s been my life the past 2-3 weeks, and while I would of course rather keep hearing that I am OK from every doctor, I don’t want to wait until that is no longer the case for me or them to act.

    Is there anything else that could possibly be causing this in the way of “polyneuropathy”? Doesn’t seem to add up, I’m very much inclined to agree with you, Dr. And if you are correct, how would I force an ER to not kick me out? I feel like they are looking at it from an imminent paralysis situation and then ruling that out, and sending me home. I could of course be totally off base on that, but I’m starting to wonder given how many times they and now my surgeon has sent me home.

    Thanks so much again for your expertise!

    Sincerely,

    Lucas C.

    SNIPPETS FROM RECENT CT AND MRI RESULTS

      From CT scan done 13 JAN 2018:

    FINDINGS:

    SEVEN CERVICAL TYPE CONFIGURED VERTEBRAL BODIES ARE PRESENT. NO
    EVIDENCE OF SPONDYLOLISTHESIS IS IDENTIFIED.
    THE ATLANTO-ODONTOID ARTICULATION IS NOT WIDENED AND THE
    PRE-VERTEBRAL SOFT-TISSUES ARE NOT THICKENED.

    THERE IS NO EVIDENCE OF ACUTE OSSEOUS INJURY.

    POSTERIOR DISC OSTEOPHYTE COMPLEXES ARE PRESENT AT C5-6 AND C6-C7
    ASYMMETRIC TO THE LEFT CAUSING MILD SPINAL CANAL STENOSIS. THERE IS
    MILD LEFT NEUROFORAMINA NARROWING.

    IMPRESSION:
    1. NO ACUTE FRACTURE OR TRAUMATIC MALALIGNMENT OF THE CERVICAL SPINE

    2. MILD DEGENERATIVE CHANGES OF THE CERVICAL SPINE MORE PROMINENT AT
    C5-C6 AND C6-C7. NO HIGH-GRADE SPINAL CANAL STENOSIS OR NEURAL
    FORAMINA NARROWING.

      From MRI done 19 JAN 2018

    THE VERTEBRAL BODY HEIGHTS ARE MAINTAINED. THE PREVERTEBRAL SOFT
    TISSUES APPEAR WITHIN NORMAL LIMITS. THERE IS NO ABNORMAL SIGNAL IN
    THE CERVICAL SPINAL CORD. THE VISUALIZED POSTERIOR FOSSA OF THE
    BRAIN AND CLIVUS ARE UNREMARKABLE.

    From MRI done 23 JAN 2018:

      Cervical vertebrae demonstrate anatomic alignment and normal bone marrow
      signal intensity, without fracture or compression deformity..
      Craniocervical junction and cervical spinal cord are normal in appearance.
      Left hemilaminectomy defect at C5-6 and C6-7 with ill-defined T2
      hyperintensity in the left posterior paraspinal soft tissues at this level.
      There is trace fluid in the left C6-7 facet joint.

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