[Donald Corenman]

#5278

I’m a 50 year old male with no prior neck or arm problems, until a July 2010 traumatic injury from a fall from a bicycle onto pavement—no helmet. Cervical CT scans were normal, but two months later I began to notice an annoying discomfort on top of my shoulder just under the clavicle. 60 days later I had agonizing pain down my left shoulder and arm. I was started on Gabapentin for the pain, which helped a lot; seven months after my accident I had an MRI which revealed herniations: At C6-7 There is a large broad-based disk protrusion which effaces CSF anterior to the spinal cord and slightly flattens the left anterior contour of the spinal cord. There is moderate bilateral neural foramen narrowing. At C5-6 there is a central and left paramedian disc protrusion which partially effaces CSF anterior to the spinal cord and which is slightly flattens the left anterior contour of the spinal cord. There is no alteration in cord T2 signal intensity There is moderate neural foramen narrowing on the right, with severe neural foramen narrowing on the left. At C7-T1 there is a mild broad-based disk bulge with axial images suggesting a small far right paramedian disc protrusion. There is a mild bilateral neural foramen narrowing. I tried traction, PT, epidural steroid injections, none of which gave any relief. By April 2011 I was up to 2700 mg daily of Gabapentin, and by May I was taking 3600 mg daily to manage the pain. Clearly, surgery was in order. Exactly one year after my accident, I had two level ACDF surgery from C5-C7. According to the surgeon, everything went well, and he said he removed “two large herniations” from my neck. I woke from surgery with no pain relief, and was in even greater pain for 30 days after surgery. Five weeks after surgery things calmed down so that I was able to reduce my dosage of Gabpentin in half. It’s now been five months post-surgery and although the pain is a little less, I’m still having bothersome shoulder and arm pain, and I can’t figure out why. My post-surgical x-rays show everything is fine and fusion beginning. Why do some people report immediate pain relief after nerve decompression, while others like myself continue to struggle months later? I might mention that I never had tingling, or pins and needles sensations, nor did I ever have motor and strength issues. My symptoms have always been pain. I am tired of being patient and “giving it time.” This pain is getting really discouraging. I wonder if I should have had the decompression surgery sooner, and that maybe I have permanent nerve damage? Your website says this surgery is successful in relieving arm pain 90-95% of the time. How many months after surgery is this assessment of recovery normally made? Thank you for any ideas! .

[Donald Corenman, MD, DC]

#5279

I’m sorry to hear that your relief is not significant as this is a very good surgery and has a long successful tract record. To look at poor post-operative results, you need to look at the diagnosis, surgery, post-operative rehab and any post-operative problems such as RSD or CRPS.

The diagnosis looks to be correct with your report of the MRI. You has significant left shoulder pain that radiated down your left arm. The MRI report notes moderate left C6-7 foraminal stenosis and severe left C5-6 foraminal stenosis. Both nerves (C6 and C7) will cause significant pain to radiate down the left arm. The physical examination can confirm involvement of these nerves and I assume that was the case.

The surgery- ACDF- is a common procedure with some technical points. If this is a disc herniation and not a bone spur, surgery consists of an indirect decompression. This means that when the foramen is opened- the disc herniation has to be “fished out” from a small 3mm opening. This is a palpation-type maneuver and there is a possibility that some of the disc herniation was not accessible and therefore not removed. A new MRI can reveal if compression is still present.

There is a possibility that the nerve had been permanently injured by the herniations. This is called chronic neuropathy (see website) and chronic pain management is in order.

You note you never had paresthesias (pins and needles) or motor weakness. This might call into question the diagnosis of compression of the nerve root as typically (but not always) those two symptoms go along with pain. There is a disorder called reflex sympathetic dystrophy or complex regional pain syndrome which is a disorder of the sympathetic nervous system and not the peripheral nervous system (which is the nerve compression we had previously been talking about). This is associated with changes in skin texture, swelling and vasomotor changes (temperature and color changes) in the skin. Do a Google search to learn more about this.

It sounds like you need to go back to your surgeon or possibly get a different set of eyes on this to determine what the cause of pain really is.

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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