[Kandy]

#31161

I had 3 level ACDF from c4/5 to c6/7 some 12 months ago and all was good, no more left arm pain/weakness/numbness. About 8 weeks ago, I started having some left shoulder/arm pain that went from intermittent to now constant for the last 5 weeks and wakes me up several times at night. Along with pain, also have numbness, weakness, and hyper reflexes. Shoulder work up was fine. Had CT with myelogram done recently. At c6/7, report says “possible small area of partial fusion anteriorly and towards the right, but without solid fusion elsewhere across disc space. There is also mild subchondral cyst formation on both sides of the disc space posteriorly and towards the right.” There is also “minimal lucency adjacent to the distal tip of the right C7 screw.” I started PT and right grip was 45 pounds while left grip was only 15 pounds. How long do you wait for full fusion to still be possible? Or, when do you decide that it is pseudoarthrosis and will simply not completely fuse? 2 years? 5 years? I am a non smoker. Also, if you do not see moderate or severe bony foraminal encroachment on CT (only see mild encroachment), can you safely assume radiculopathy is unrelated to non union and symptoms are generated by a different issue? Also noted on report was mild congenital spinal canal stenosis.

[Donald Corenman, MD, DC]

#31165

It is possible but highly unlikely that a cervical (non-fusion) pseudoarthrosis at C6-7 will go on to fuse after 12 months. Did the surgeon use your own bone (autograft), donor bone (allograft) or a PEEK (plastic) cage with bone substitute (demineralized bone matrix-DBM)?

Could you have degenerative breakdown at C3-4 above the fusion mass that could be causing shoulder (but not arm) pain? Yes. However, the C3-4 level (the C4 nerve) does not go down below the shoulder into the arm.

Grip weakness typically develops from compression of the C8 nerve (C7-T1 level-the level below the last fusion level at C6-7 where you have your pseudoarthrosis).

If you have motion at the pseudoarthrosis level, this could cause your symptoms even if there is no severe compression at C6-7. A selective nerve root block could help to diagnose your pain origin.

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.

[Kandy]

#31173

Thank you for your reply. I had allograft and the other two levels are fully fused.

As for levels above and below fusion per CT myelogram report, at C3/4 there is a “mild broad-based 1 mm central disc protrusion and early left-sided facet arthropathy; there is mild spinal canal stenosis mostly congenital in nature.” At the C7/T1 level, there is “a 1 mm disc bulge and mild spinal canal stenosis; there is mild right-sided facet arthropathy with mild right foraminal bony encroachment, and no left foraminal bony encroachment is seen.” Disc bulge and/or protrusion at C3/4 and C7/T1 were not noted in the CT and MRI reports that were done prior to ACDF surgery a year ago. Since the main adjective used is “mild” to describe findings in these levels above and below the fusion, I assumed these areas are not the pain generator(s)?

As for motion, the CT myelogram report says “no subluxation is seen.” However, a flexure/extension x-ray done about 2 weeks prior to the CT myelogram shows some mild motion: “Lateral alignment is normal in neutral position. 1 mm anterior subluxation of C3 on C4 in flexion with 2 mm posterior subluxation of C3 on C4 in extension. Sclerosis of the middle and lower cervical facet joints.” Or, are you talking about motion between the spinous processes at C6 and C7 when comparing flexion to extension?

[Donald Corenman, MD, DC]

#31174

“Mild” is generally radiologist vernacular for “not too big a deal”. The CT however does not account for increased motion that could lead to instability so flexion/extension X-rays are necessary to compare for motion.

Selective nerve root blocks with a pain diary are the best way in my opinion to determine pain generation.

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.

[Kandy]

#31310

Hello Dr. Corenman,

Thank you for your previous responses and answers to all of my questions. I just wanted to give you an update. I recently went for a 2nd opinion, as my original surgeon told me to try PT, TENS, massages, and come back in 3 months. The new surgeon looked at CT w/myelogram and said that there was a bone spur that could be impinging the nerve root. He did concur with what you said that an SNRB could help determine if the spur was indeed the pain generator. He did not see an immediate reason for the weakness, which is progressively worse. Instead of doing the SNRB right now, he is sending me for nerve conduction and EMG testing. Also, he did confirm that looking at my flex/ex xray from August, there is > 4 mm difference across spinous processes at C6/7. Even so, he seems to think that there is still a good chance to achieve fusion at that level.

MY PT did a bit of an experiment. In supine position, she pulled my head in slight traction. That eased my arm/shoulder pain by about 2 notches on a 10 scale. Also in supine position, she gave me a 2# weight to lift with my left hand, extending my tricep. I could not lift it quite halfway up before my arm started repeat the experiment again. This time, I was able to get the 2 # weight all the way up, and my arm did not start quivering until about 3/4 of the way up. It was a definite improvement, but not a return to “normal level”. I do not think I could have raised a heavier weight, even with the traction.

I am beginning to notice more and more how the left arm and grip weakness are effecting my day to day living. It is annoying to ask for help in the simplistic of things like opening a jar or pushing down the back SUV seat.

[Donald Corenman, MD, DC]

#31311

I think your new surgeon is doing well. An EMG/NCV can be helpful long as you have weakness which it sounds like you do. The SNRB is also a good idea. Traction can be helpful in foraminal stenosis but with a prior attempt at a fusion, that level should be so stiff that traction should not help. It does, so maybe the level is not as stiff, meaning a “loose” pseudoarthrosis.

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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