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  • westie California
    Participant
    Post count: 135

    Good afternoon Dr. Corenman,

    My question is regarding possible inadequate decompression after 5 level ACDF (C3-C7), 5 level laminectomy/fusion (C3-C7), 3 level foraminotomy (C5-C7) and 3 level facetectomies (C5-C7). I’m still having neck pain, painful muscle spasms, headaches, biceps pain, and shoulder’s pain. I know one can have chronic radiculopathy, muscle trauma, etc. that can cause the above. Is there a gauge that surgeon’s use to determine how much of the residual compression maybe causing a patient symptoms, i.e. moderate compression verse severe? My recent diagnostic workup includes:

    **EMG (2021)**

    Abnormal study, electrodiagnostic testing reveals evidence of left C5-6 cervical radiculopathy without distal denervation. There is also evidence of left median neuropathy at the wrist without distal denervation. The chart shows issues with Left Biceps Musculocut Nerve C5-6 “Reduced” and Left Triceps Radial C6-7-8 “Reduced”

    **6 VIEWS OF THE CERVICAL SPINE (2020)**

    On the oblique views, osseous proliferation results in up to moderate neural foraminal stenosis on the left.

    **CT SCAN (2020)**

    C2-3: Tiny central disc herniation. There is associated minimal mass effect on the anterior thecal sac without significant central canal stenosis No significant change.

    C3-4: No significant disc disease. Bilateral uncovertebral spurring and bilateral facet arthropathy, mildly progressive since 5/19/2018. There is associated mild right and moderate to severe left foraminal narrowing.

    C4-5, C5-6, C6-7, C7-T1: Postsurgical changes. No significant disc disease. Spondylitic ridging and uncovertebral spurring at C4-5, C5-6 and C6-7, mildly progressive since 5/19/2018. There is associated foraminal narrowing, mild on the right at C4-5 and C5-6, mild on the left at C6-7. No significant foraminal narrowing at C7-T1. No significant central canal stenosis at any of these levels

    **MRA**

    Mild to moderate extrinsic compression of subclavian veins on hyperabduction without distention or thrombosis in neck veins or cephalic veins.

    *****Consultation with Neurosurgeon*****

    Developed fixed post laminectomy Kyphosis at C7-T1. A pedicle subtraction osteotomy would need to be performed to correct this deformity and reduce pain.

    *****Consultation with two Physiatrists*****

    Source of pain is highly due to lack of foraminal decompression. There’s a solid fusion from C3-T1. After anterior and posterior decompression surgeries any residual compression can cause symptoms, can’t recall one case that had residual compression.

    Can you give me your thoughts on this please? Thanks

    Donald Corenman, MD, DC
    Moderator
    Post count: 8140

    You report a “5 level ACDF (C3-C7), 5 level laminectomy/fusion (C3-C7), 3 level foraminotomy (C5-C7) and 3 level facetectomies (C5-C7)” however the radiologist would differ with that. He or she noted a C4-T1 fusion so you might have your levels mixed up.

    At C3-4 (the level above the fusion), there is “mild right and moderate to severe left foraminal narrowing” which could cause left-sided neck, anterior chest wall and shoulder pain.

    At the fusion levels, he or she notes; “There is associated foraminal narrowing, mild on the right at C4-5 and C5-6, mild on the left at C6-7. No significant foraminal narrowing at C7-T1”. Mild narrowing does not typically cause nerve root symptoms. He or she however does not comment on solid fusion status and lack of fusion can cause pain.

    The neurosurgeon noted “Developed fixed post laminectomy Kyphosis at C7-T1. A pedicle subtraction osteotomy would need to be performed to correct this deformity and reduce pain”. He did not comment on fusion status unless the term “fixed” means solid to him. There was no comment on the amount of angulation (“kyphosis”). What surgery he is describing is a huge undertaking fraught with potential complications.

    The two Physiatrists note a solid fusion but I would not depend upon that assertion. They also note that pain is a result of residual foraminal stenosis which is not found by the radiologist or the neurosurgeon. Do these two Physiatrists work together?

    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.
    westie California
    Participant
    Post count: 135

    Good evening Dr. Corenman,

    The physiatrist’s does not work together. I’m attaching the CT Scan report below:

    ***CT Scan****

    FINDINGS:

    Postsurgical Changes: Postsurgical fusion changes, appears to reflect a revision/addition since 5/19/2018, now appears to involve C3-T1 with multilevel postoperative hardware and decompressive laminectomies. Hardware appears intact, appropriately positioned without evidence of failure or loosening. Bony fusion appears solid at C3-4 through C7-T1.

    Alignment: Lordotic straightening.

    Vertebrae: Normal in height.

    Soft Tissues: Expected postoperative changes.

    Disc Spaces:

    C2-3: Tiny central disc herniation. There is associated minimal mass effect on the anterior thecal sac without significant central canal stenosis No significant change.

    C3-4: No significant disc disease. Bilateral uncovertebral spurring and bilateral facet arthropathy, mildly progressive since 5/19/2018. There is associated mild right and moderate to severe left foraminal narrowing.

    C4-5, C5-6, C6-7, C7-T1: Postsurgical changes. No significant disc disease. Spondylitic ridging and uncovertebral spurring at C4-5, C5-6 and C6-7, mildly progressive since 5/19/2018. There is associated foraminal narrowing, mild on the right at C4-5 and C5-6, mild on the left at C6-7. No significant foraminal narrowing at C7-T1. No significant central canal stenosis at any of these levels.

    Spinal Canal Contents: Limited by CT technique, grossly unremarkable

    You note “At C3-4 (the level above the fusion), there is “mild right and moderate to severe left foraminal narrowing” which could cause left-sided neck, anterior chest wall and shoulder pain”. I have anterior chest wall pain, with left more than right neck and shoulder pain.

    The EMG also states ” Needle evaluation of the left biceps and the left triceps muscles showed diminished recruitment. The left mid cervical paraspinal muscle showed moderately increased spontaneous activity. Left Biceps Musculocut Nerve C5-6 “Reduced” and Left Triceps Radial C6-7-8 “Reduced”

    I have the following questions please Doctor:

    1. Does the information above show perhaps a posterior foraminotomy at left C3-C4 can alleviate the anterior chest wall, shoulder and neck pain?

    2. Can foraminal stenosis on left side C3-C4 cause pain and spasms additionally on right also?

    3. “Paraspinal muscle showed moderately increased spontaneous activity” is this due to surgical muscle trauma or nerve root stenosis?

    4. I sill have base of neck pain bilaterally still waiting for T2-T3 to fuse. EMG states “electrodiagnostic testing reveals evidence of left C5-6 cervical radiculopathy without distal denervation”. It sounds from your previous correspondence, that maybe chronic radiculopathy persists at this level since “Mild narrowing does not typically cause nerve root symptoms”

    5. Should nerve blocks be in store for C3-C4 and C5-C6?

    6. My last question is currently in physical therapy for the past 4 weeks. The Doctor of physical therapy tells me during my massages that my traps gets tighter and tighter with motion to the point where they feel rock solid. They place me on my back and hold my neck with their hands with very little load of my neck weight on my spine and turn my neck gently to the left and right like a windshield wiper. They can’t seem to understand why motion is making matters worst. I’ve done some research and it appears that this can signal pseudarthrosis and I’m really confused since the radiologist notes “Bony fusion appears solid at C3-4 through C7-T1”, however he goes on to say “Spondylitic ridging and uncovertebral spurring at C4-5, C5-6 and C6-7, mildly progressive since 5/19/2018” sounds like there’s some kind of continued motion still going? So maybe the focus should be on posterior foraminotomy at C3-C4 left and perhaps revision ACDF’s at C4-5, C5-6 and C6-7? Do you have an information you can share on this? What is the protocol? Is this a case where a surgeon would have to use his/ her judgement and go in to inspect fusion status? If there’s a solid fusion, how about an anemic fusion, where there’s still some kind of motion going on? How can this construct be reinforced?

    Thanks again for all your help! This pain is driving me nuts, I’m beyond fatigued, just doing my best to see if any information you provide will help in my journey to get this issue behind me. Thank you again for all your help, time, making this forum available for those who are struggling and not giving up, your feedback is giving us hope and may the lord, give you continued blessings and health, you deserve the best. Best regards Dr. Corenman

    Donald Corenman, MD, DC
    Moderator
    Post count: 8140

    Before you consider further surgery, you need some diagnostic injection blocks. You also need to know that diagnostic injections will anesthetize both a chronic nerve root injury as well as a painful compressed nerve root. This means you will note relief from the injection in either case. If you undergo another decompression, this may not give you the relief you desire if you have a chronic nerve root injury.

    Can foraminal stenosis on left side C3-C4 cause pain and spasms additionally on right also? No

    “Paraspinal muscle showed moderately increased spontaneous activity” is this due to surgical muscle trauma or nerve root stenosis”? This is due to prior posterior surgery and should not be considered diagnostic.

    “I still have base of neck pain bilaterally still waiting for T2-T3 to fuse. EMG states “electrodiagnostic testing reveals evidence of left C5-6 cervical radiculopathy without distal denervation”. It sounds from your previous correspondence, that maybe chronic radiculopathy persists at this level since “Mild narrowing does not typically cause nerve root symptoms”. EMGs will determine arm pain but has no bearing on neck pain in general. You probably do have chronic radiculopathy.

    “Should nerve blocks be in store for C3-C4 and C5-C6”? If there is no significant compression, then SNRBs might help for nerve inflammation but wont help for diagnosis as there is nothing to fix.

    You need a second opinion spine surgeon or radiologist to help determine the presence of a solid fusion or not. X-rays including flexion/extension can also be helpful. It’s possible that it might be better to find a specialist who does not know your current physicians.

    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.
    westie California
    Participant
    Post count: 135

    Good evening Dr. Corenman,

    I was reviewing my cervical laminectomy operative notes from 2013 and have a few questions please. It reads “OPERATION PERFORMED: Bilateral decompressive laminectomy from C3-C7 with bilateral posterior instrumentation and fusion using Medtronic’s instrumentation at C3, C4, C5, C6 and C7 with fusion from C3-7 bilaterally using allograft bone graft with Grafton bone protein bilaterally as well as autogenous bone bilaterally”.

    My questions are:

    1. Grafton bone protein is this off label for cervical spine? Thought FDA approved for lumbar spine?

    2. Can Grafton bone protein cause neck pain, chronic radiculopathy, trapezoids spasm, etc.?

    3. What can be done if this is an issue?

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