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  • drbourque
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    Hello, Dr. Corenman.
    I am a chiropractor in Louisiana and would value your opinion on my personal findings. I am a 5′ 7″ 197#, 44yoa white male with history of neck pain radiating into the right suprascapular, posterior scap and deltoid areas for the past month. Visible atrophy of the anterior and middle deltoid and biceps. Grade 3 motor deficit of middle deltoid, grade 3+ anterior deltoid and grade 4 biceps developed just prior to taking the MRI. No sensory changes (sharp and vibratory). No lower extremity involvement. No balance problems. No change in bowel or bladder function. History of medial and lateral epicondylitis on the right. Transient right interossei spasm with pinching or gripping at times. Left grip strength slightly decreased (15%). X-rays show mildly decreased lordosis, mild anterior weight bearing, moderate disc thinning with anterior osteophyes at C5-6. Multilevel uncinate hypertrophy. MRI 6/24/14 shows the following significant findings:
    C2-3: No disc protrusion or central canal or foramen stenosis. The facet joints appear mildly arthritic.
    C3-4: There is a disc bulge pattern. It extends dorsal to the disc space by 1mm. Moderate to severe bilateral foramen narrowing by uncovertebral hypertrophy. There is still trace CSF in the left root sleeve. The right C4 root sleeve is attenuated and CSF visualization. Mild DJD of the facet joints.
    C4-5: There is central and paracentral to the right soft disc protrusion and osteophyte complex causing a tight right foramen stenosis. The cord is rotated counterclockwise but not compressed. The left foramen is patent. There is mild facet arthropathy.
    C5-6: There is a disc bulge extending dorsal to the disc space by about 1mm. There is moderated left and more severe right foramen narrowing by uncovertebral joint hypertrophy. Mild to moderate facet arthropathy. The central canal is patent.
    C6-7: There is a midline soft disc protrusion. It extends greater to the left and extends dorsal to the disc space by 4mm. I causes central canal stenosis, but no cord signal abnormality. there is narrowing of both foramen especially severe to the left by the disc protrusion and osteophyte and on the right less so by uncovertebral joint hypertrophy. there is facet arthropathy.
    C7-T1: Within normal limits
    No spondylolisthesis. No adjacent neck soft tissue abnormalities.

    Treatment to date has consisted of Cox cervical traction, Graston of the cervical region and right shoulder girdle. Eye field exercises (pursuits and saccades), coupled reduction of C5 and C4, left cerebellar and right cortex stimulation according to exam finding from a Chiro Neuro (DACAN). Massage and trigger point therapy to splinted muscles in the upper thorax and cervical region. Cervical traction decompression in my office (which seems to give the most relief) two to three times per day. I also received an epidural steroid injection to C4-5 and C5-6 about a week ago. A prescription of gabapentin was given for the radicular pain.

    Ranges of motion are improved, but still restricted. Right deltoid and biceps strength is improving slowly with strengthening exercises.

    I have no other significant medical history.

    I am scheduled to consult with three other neurosurgeons to discuss my options within the next couple of months. Could you determine from these findings, what surgical procedure, if any, would be recommended? And what are the recovery times for each? Obviously, I would rather not have surgery, if at all possible. Are there any minimally invasive techniques available for this sort of condition and what does the recovery entail? Obviously I am concerned about my ability to practice.

    Thank you in advance for taking the time to read this post. Your input is greatly appreciated.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8656

    Deltoid weakness is a C5 nerve root problem and C6 innervates the biceps muscle. You have significant C4-5 compression (C5 root-“tight right foramen stenosis”) and C5-6 compression (C6 root-“moderated left and more severe right foramen narrowing by uncovertebral joint hypertrophy”).

    This requires some thought process to go through the various scenarios to understand what to do.

    C6-7 is not wonderful as there is both foraminal and central stenosis. Unfortunately, your C3-4 level is very degenerative too.

    Sometimes surgery is necessary even though we don’t want to consider it. Nerve compression that causes motor weakness is serious and might not be recoverable even with surgery. It is this situation that surgery needs to be considered to allow the best chance for recovery of motor strength.

    Based upon your report, the two levels at C4-5 and C5-6 have to be incorporated in the ACDF as these levels cause your current motor weakness (C5 and C6 roots). It is important to free up the nerve roots to have the best chance to allow them to recover, especially with your occupation being a chiropractor.

    The level at C6-7 is very degenerative and includes central stenosis as well as severe foraminal stenosis. I don’t think you can “park” a fusion on top of this level (C4-6 ACDF) without causing this level to become symptomatic. Therefore this level needs to be part of the surgery.

    The flexion-extension x-rays would be important to know how much range of motion you have in C3-C7. If these levels are as degenerative on X-ray as on the MRI, there should be very limited range of motion. This is important as you are probably looking at an ACDF (fusion) of at least three levels and probably four.

    The question is what to do about C3-4. This level does not contribute any motor nerves to the upper extremities so this level is not contributing to your weakness. Depending upon this level’s contribution to your current pain, it may or may not need to be addressed surgically. C3-4 can contribute to neck pain, especially due to the root compression (“Moderate to severe bilateral foramen narrowing by uncovertebral hypertrophy”). This can be determined by a selective nerve root block of C4 and a pain diary (see website).

    If the C3-4 level is very stiff based upon the motion x-rays, surgically including it might not cause any significant problem to you in loss of range of motion. This does however mean a four level ACDF which will make your neck stiffer somewhat. You could continue your career but you might not want to consider a change in career to boxing or long distance running.

    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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