[Kay49]

#8015

Dear Dr. Corenman,

Stats: 49 year old female. Car accident, major whiplash 1990. Two more rear end collisions (like the first), minor, but more jarring of neck, five years later, then one year after that.
Chiropractor after first accident ‘cracked’ neck several times leading to terrible pain. Never saw a real doc after accident. Pain on/off through the years, never thought much about it.
FF to 2010: New symptoms: facial numbness. increased neck pain, range of motion diminished. Intermittent pain in legs, occasional numbness and tingling. Neck pain increasing. Lots of popping/cracking noises. Deep pain from shoulder into back. Lightning like pain down shins, into left arm, outside of arm, into all fingers on both hands and a feeling of fullness and pressure in all ten fingers with numbness,left foot pins and needles, legs numbing doing nothing to create numbness. Pain at site of cervical stenosis increasing. Headaches that are frequent from back of skull to top of head. I cannot now turn my head to look out my back window in reverse in my car. Lower back begins to bother me. DX’d with sciatica. Take low dose pain med, alternating ibuprofen, stretching, mile walks in effort to strengthen. Increased my activities due to concern about weakness and alarming increase in pain in legs, tingling. numbness. Dropping things more. Cannot pick up small items like change, without concentration, cannot grip them. Stumbling when walking, all intermittent. range of motion decrease continues. Pain in legs has massively increased the last two months. Pain at the site of cervical stenosis increasing, and deep pain in left arm. Because all of these symptoms have developed over two years, it was a little like a crazy making abusive boyfriend…is it me, or is it HIM? Is it my neck,lower back or just me…until a week ago. I picked up a laundry basket tub (very large) full of wet towels to take to laundry mat. I felt a sudden lightning like pain and then a dull thud like feeling in my back. I had the clothes almost to the ground, so I stayed bent over until I was sure that was not coming back. Got up resumed my day, nagging pain in back. Next day..I could barely get out of bed. Pain increased throughout the day. I was also scheduled for an EMG and I could not bear it, so had to reschedule I’ve been waiting to see a neurosurgeon for a year. They would not see me unless I had an EMG first. I went immediately home and rested on heating pad. pain continued to increase from lower back, through buttocks down legs and a horrible pain shooting into my foot. I awaken each day and have for several months with a lightning like shooting pain from my feet straight to my back. walking has begun to really become painful. Most days my leg pain is deep and my legs feel heavy and weak when standing too long. Anyway, wound up in ER with an unbearable pain I’ve never experienced before in my life. I tried to hold off, telling myself it was just me but I could no longer tolerate the pain. MRI was done, no significant change from last MRI this last June, but there are neurological changes that suggest something wrong with my reflexes although I was not told what. Ironically, the doctor seeing me in the ER, called the neuro who reviewed my case and wanted the EMG first. After he heard about the MRI and physical and pain level with the back issue, we are bypassing EMG for now and he wants e to call Monday morning for appt with him. Finally..

Okay, so brief descriptive of my MRI from June:
C 4-5 There is a mild central disc osteophyte complex which minimally effaces the ventral thecal sac but causes no significant canal stenosis or cord flattening. No significant foraminal narrowing.

C- 5-6- There is a central disc osteophyte complex which effeaces the ventral thecal sac and flattens the cord with moderate canal stenosis. Unconvertebral hypertrophy results in mild foraminal narrowing. The left foramen is patent.
C6-7- There is a central/right paracentral broad based disc protrusion which effaces the ventral thecal sac and results in moderately severe canal stenosis. There is moderate right foraminal narrowing.

Oddly enough, the cord flattening is not mentioned in the “impression’ part of the read. The cord has normal signal intensity. There is mild straightening of the normal cervical lordosis.

Lumbar:

L2-L4 There is mild circumferential disc bulging and mild facet changes. No foraminal narrowing
L4-L5- There is a mild circumferential disc bulging and mild facet changes. No canal stenosis or foraminal narrowing
L5-S1-There is a small central disc protrusion with an associated annular tear. No stenosis, no foraminal narrowing and no impingment.

Questions: Since my cervical spine is not showing signal changes, but cord flattening, is it insignificant? While my symptoms have gradually increased, is it even enough for a spinal surgeon to consider it surgically worthy? These symptoms, collectively, are taking a toll now, on my activity levels, which are slowing down. Also I have had significant weight loss of ten pounds over the last three weeks and continued muscle weakness on the left side. Could these be associated?
Can an steroidal injection be done on a cervical spine where the cord is compressed? Can myelopathy be present without signal changes to the cord?
I was dx’d in the ER with lumbarsacrol radiculopathy. I assume this to be a fancy medical term for ‘sciatica’. Why is my lower back more painful then my neck? My neck pain has subsided with extremity symptom increase and now my lower back has symptom increase with pain and most especially in my legs. My skin is sensitive to the touch in these areas as well.

I am in good health otherwise. I do not wish to wait for symptom increase, disability and age to put off the inevitable. It is very frustrating to have BOTH cervical and lumbar. I’m sure you have seen people with both in your practice.

OTher than the questions asked above, is it even worth pursuing a neurosurgeon for potential surgery upon my neck? It’s the cord compression that most concerns me and the extremity symptom increase. I trust you will give me a totally straight answer on this one.

Thank you so much for reading.

[Donald Corenman, MD, DC]

#8029

You have diffuse symptoms with many potential causes. The stenosis (narrowing of the canal) is the most serious of your MRI findings. The fact that you have no cord signal change does not mean that the cord could not malfunction due to compression. See the section on the website under myelopathy.

You really do need to see a spine specialist for a complete evaluation. There are various examination findings that would yield information regarding your current situation.

Cervical stenosis that causes cord dysfunction is typically painless. The spinal pain that you experience is most likely originating from the discs and facets that degenerate (which causes the cord compression).

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.

[Kay49]

#8052

Dr. Corenman,

Thank you very much for your response. I have another question for you and your willingness to be forthcoming is important for me and my health.

I am on medicaid (need I say more?) and I have been trying to see a neurosurgeon for over a year. I have been blown off time and again, however with due diligence and persistent by my PCD, insurance advocate and myself, I managed to make a little headway (not saying much). After the neurosurgeon reviewed my case, he said he wanted an EMG BEFORE he would see me. Without getting into too much politics, to me this is code for ‘If the EMG shows nerve issues THEN we will see you, otherwise, it’s a NO GO’. I was told that this EMG was needed to know best what ‘treatment’ I would be needing. After hours of research, I’ve learned code when it comes to very unfortunate circumstances (my own with this ‘disease’), the great expense that neurology and surgery is (of course I would have issues with the most expensive-potentially), and medicaid that doesn’t pay nearly enough to access the services of a neurosurgeon, hence all the blowing off.

I scheduled the EMG for last week, and ironically the day before, picked up an overwhelming tub full of drenched towels (mistake) felt a sharp pain in the lumbar area, and a ‘thud’ like feeling at the same time. This would be my introduction to an acute flare of what is now dx’d as lumbarsacral radiculopathy. Upon MRI findings, I have at L3-L4-minimal circumferential disc bulging and mild facet degenerative changes. L4-L5- Mild circumferential disc bulging and mild facet degenerative changes. L5-S1- A small central disc protrusion with an associated annular tear. This results (all of the above as well) in no significant canal stenosis, foraminal narrowing or definitive (key word) nerve root impingement. Mild face changes bilaterally.

No big deal. It’s been REALLY fun to have BOTH going at the same time, eh? Anyway, the next day after this incident, the pain was unbelievable and growing worse by the hour. I have had pain, heaviness and weakness in my legs, growing gradually worse over the last year, more so the last few months. My exercises and stretches, walking had grown painful just prior to this. I have never experienced an acute flare and I hope I never do again! I got to my EMG and could NOT sit still for the procedure. I rescheduled. At the ER, the ER doc heard my story and contacted the Spine health center and guess who was on call? The neurosurgeon who reviewed my case. He said he wanted to put himself down as the follow up doc and to call his office first thing Monday morning. Unfortunately, I’ve heard nothing.

I want to ask your clarification the reasons why a neuro would ask for an EMG BEFORE they see you, medically. I would think a responsible neuro would consider the patients OVERALL picture with regards to symptoms and not just an EMG for weighing out insurance issues or ability to pay. I know that if I had private insurance, this would NOT be an issue.

My health is important to me. I’m fine if a neuro tells me they can do nothing, but with what appears to be the seriousness of stenosis, compression, combined with symptoms, I think an evaluation is warranted. I don’t think a medicaid patient should be deemed less than one who has ability to pay, but I know the truth of that, reading stories of so many who are suffering needlessly.

My next question for you is with regards to surgery. This is a ‘disease’ that is progressive. Some faster than others, some with symptoms, some not at all and some in between. Why are conservative treatments tried before a surgery is just done and over with? I know there is more to consider than this per patient and it’s not always black and white, but from what I’m reading this too has become an insurance issue for most, rather than a health issue because logically since it’s progressive, doesn’t it make sense to have surgery done and HALT progression for awhile, or to minimize what will surely be MORE damage later?
I’m also very much against epidural cortisone shots. I see NO purpose in something that seems so risky, is anxiety provoking and painful only to hold off the inevitable: surgery.

I may consider this for lumbar, but with the compression and stenosis in my neck it’s a big NO. WAY.

I guess what concerns me is the stenosis and compression. I can’t ‘see’ what’s going on, only understand my symptoms as I subjectively experience them.

Anyway, any response is appreciated to broaden my understanding and research about my spine issues.

[Donald Corenman, MD, DC]

#8053

An EMG is a test that will determine if nerve compression is causing motor weakness. It will not show if nerve pain is present. It will not demonstrate cord compression. It will not determine what is causing neck or lower back pain.

Your lower back pain seems to be from tears of the annulus (see degenerative disc disease on the website). At this point, I see no need for surgery for your lower back. Surgery will not stop the genetics of the degenerative changes.

I cannot tell you why the neurosurgeon wants the EMG. I find EMGs not to be useful under many circumstances.

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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