[mdrizzo1]

#5777

Hello, I am currently 6 months out from a two level ACDF (c4-c6). My original symptoms were bilateral, symmetrical muscle aches/burning in my arms (wrists, forearms, deltoids). Both herniations were central (pushing into the cord, right up the middle) and I never had numbness or tingling, just pain/tightness.

I did all the conservative treatment (shots, PT, traction) and finally after 2 years gave in and had the ACDF. My arm pain cleared up shortly thereafter.

Now, 6 months later, I’m told my by my surgeon my fusion is healing perfectly and xray confirms this. But I am having excruciating muscle spasms/tightness in my thoracic spine and trapezius muscles and in between my shoulder blades. My upper traps and entire upper back is constantly in spasm. I feel stiff as a board and pop/snap when I move and I’m only 28. Something pops when I breathe in – I feel like my back “needs to pop” all day long. I’m being told by my surgeon this is a postural issue. X ray of T-spine is negative for any issues there.

Doing PT, home exercises and even dry needling, to no avail, it always comes back. Is this normal 6 months after a fusion to have these spasms in my upper back? My low back is fine, no problems there!

[Donald Corenman, MD, DC]

#5783

Your symptoms and intensity of pain are concerning. A number of potential diagnoses are possible. See the section on the website regarding failed neck surgery syndrome.

There may be a pseudoarthrosis (lack of fusion) of one of the two levels. A CT scan can reveal this.

There may be a herniation at a level above or below and an MRI would reveal this possibility.

There may be a separate shoulder problem (less likely but possible) and a well done physical examination would sort this out.

You may have a problem with a rib head where it inserts into the spine. Chiropractic treatment can be effective if this is the case.

You may even have a thoracic disc herniation (rare but possible). A thoracic MRI would reveal this disorder.

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.

[mdrizzo1]

#6599

Dr. Corenman,

After several rounds of facet joints injections, constant NSAIDS and muscle relaxers, my symptoms in my original post have persisted. (thoracic/paraspinal and trapezius pain/spasms – upper/mid/lower trapezius and paraspinals. No lumbar pain). I am now 10 months out from the ACDF.

I was sent back for a C and T MRI. The results are as follows:

C spine:

Findings: Lower posterior fossa is normal. Craniocervical junction is intact. There is straightened cervical spine lordosis with preserved alignment, normal marrow signal, and no prevertebral soft tissue swelling. There has been interval anterior cervical discectomy and fusion C4-C6 and C5-C6 with apparent osseous integration of the intervening bone graft material.

C2-C3: No abnormality.
C3-C4: Minimal right uncovertebral hypertrophy. No disc protrusion or mass effect.
C4-C5: Canal is decompressed status post fusion and discectomy.
C5-C6: Canal is decompressed status post discectomy and fusion. Recesses and foramina are patent.
C6-C7: Very subtle and minimal less than 1 mm grade retrolisthesis C6 on C7 without disc protrusion or mass effect
C7-T1: No abnormality

The cervical spinal cord demonstrates normal caliber and signal without syrinx. There is no abnormal enhancement or mass.

Impression:
1. Status post ACDF C4-C6 with decompressed canal, recesses, and foramina.
2. No new disc protrusion or mass effect upon the canal.
3. Cervical spinal cord demonstrates normal caliber and signal with syrinx or abnormal enhancement.

T spine:

Findings: The thoracic vertebral bodies are aligned with normal marrow signal. There is very mild exaggeration of thoracic kyphosis. Paraspinal tissues are intact.

There is nonacute endplate Schmorl’s node T7-T8 with small central disc protrusion without mass effect. Disc dessication with loss of height T8-T9 with mild posterior endplate degeneration and small central disc protrusion without mass effect. Small central disc bulge T10-T11 without mass effect.

Cord terminates at T12. The thoracic spinal cord demonstrates normal signal and caliber w/o syrinx.

Impression:
1. Small disc protrusions mid and lower thoracic spine w/o mass effect.
2. Thoracic spinal cord is normal

As a healthy (except for this) 28 year old, it seems concerning my spine is falling apart. To the layman (me), it seems like my neck fusion was successful, and now my thoracic has some issues. The Schmorl’s node mentioned at T7-T8 is I believe right about where my pain is worst(lower between my shoulder blades). The T8-T9 dessication I knew about from a MRI 2 years ago, although that was the only issue and was causing me no pain at the time.

Although the MRI mentions no mass effect, if I was your patient what would be your recommended course of action? I would certainly prefer a conservative approach of course. Much thanks.

[Donald Corenman, MD, DC]

#6613

The MRI might note solid fusion but the MRI is generally not a reliable test to determine if fusion is present. This MRI however does note no evidence of compression of neurological structures so unless there is a lack of fusion, the neck is probably not the source of your pain. A CT scan however would eliminate that lack of fusion diagnosis for pain generation as the CT test is the gold standard for determining if fusion is solid or not.

Thoracic pain (not generated from the cervical spine) could be from disc, facet or nerve origin. The MRI notes degenerative changes of the disc and no evidence of nerve of cord compression. Facet generated pain will not be demonstrated by an MRI and has to be diagnosed by facet blocks (see website). Disc pain is generally diagnosed by discograms but I generally do not recommend discograms in the thoracic spine. Also, discograms are a pre-surgical test which is again not generally recommended in the thoracic spine.

An epidural injection may help relieve symptoms at the level of the degenerative disc.

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.

[mdrizzo1]

#7100

Thank you, I am pursuing the CT scan. My surgeon constantly reiterates “your neck is fused, it’s not your neck”, frustrating.

One additional question…if the pain was facet originated, wouldn’t the facets directly below the fusion site (in my case C4-C6 ACDF) bear the brunt of the new load? (around C6-C7?) My pain management doctor did two rounds of facet injections at T3-T6 which provided no relief. Then a cervical epidural (no relief). That is roughly where my pain/stiffness is located (between shoulder blades/thoracic), but I’m wondering if the pain is stemming from directly below the fusion site and if that “maps” to my shoulder blades/rhomboid area. Thank you.

[Donald Corenman, MD, DC]

#7102

If you have already had facet injections in the area of your thoracic pain, you can generally rule them out as a pain generator. If the cervical facets are causing pain, it is possible that they are referring to the mid thoracic spine but less likely.

A cervical epidural should have yielded at least short term relief if the symptoms originated from the nerves of the spinal canal.

The differential is now down to facets in the lower cervical spine, thoracic degenerative disc disease, neuropathic pain syndrome, Scheuermann’s disorder or a rib/vertebral articulation (as long as the ACDF is a solid fusion). Don’t forget that other structures can refer pain to that area (heart and thoracic aorta among others).

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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