[jefish]

#24543

Hello Dr. Corenman,

I posted here a few years ago but I will give you my history and would love your opinion on what to do next. I had an ACDF in 2013 C4-C6, with PEEK cage from a spine institute, was 28 years old at the time. Had incident that occurred that I think led to breaking my fusion. Long story short, after much neglect finally diagnosed with failed fusion. Sought opinion from highly regarded neurosurgeon, he recommended Anterior revision. I decided to go with him for revision. Revision surgery 2015, He removed devices and used allograft w/ spine bone marrow asparate with plating across surgery site. He also perform ACDF at C3 because he had no where to attach screws to because the bone was ribbon thin according to him from the damage of the non-union from first surgery. So at that time 2015 ACDF C3-C6. I started physical therapy at 3 months after surgery and it seemed to hurt me more than help. I think PT may have hurt me, not sure. Time goes on I seem to go down hill as far as how I feel and my symptoms got worse. November 2016, Having severe radiculopathy down my arm into my fingers. Felt like an electric shocker in my arm, extremely painful. Had epidural injections which did relieve the radiculopathy shocker , burning pain, but the deep aching pain in my neck remained. My surgeon suggested more surgery. His diagnosis, I had a non-union at the C5-C6 area (only slightly) , C6-C7 area ADD (collapsing), C3-C5 solid fusion. He recommended 360 degree surgery. He wanted to do in 2 stages do revision ACDF and wait 1 month then do posterior fusion. I got two other opinions one from Duke and another in Charleston. One said he would address posterior only, the other said he would only do ACDF on C6-C7 and leave the rest like it was anteriorly and flip me over and perform posterior surgery, same surgery. I elected to go with my original surgeon and his plan. Here is my question for you I had the ACDF revision Feb. 23, 2017. It was the worst surgery of them all to go through as far as recovery. He removed plate across previous fusion. He said the fusion was really good C3-C5, in fact so good he broke two screw drivers trying to remove the screws. My surgeon said the non-union was only a hairline non-union but he repaired it. There was a strange issue also. He said my bone was soft there and they had drilled down to get to hard bone. He said the tissue looked grey / black matter there, which was a concern. He performed ACDF C6-C7 also. He used 8mm grafts. They biopsied and sent off the tissue. Said it was an issue with metal artifact and my body rejecting the metal particles from previous non-union. He said he thinks it was from the motion of the first surgery because those (PEEK) screws go in at angles up in the disc area. I don’t know. Presently, it is almost one month post ACDF revision surgery. Now fused C3-C7. I have left shoulder scapular pain (which I’ve had since first surgery). I have a huge knot on my left scapular. I have neck pain at the base of my scull on right side and some left, but getting better. I’ve had these two pain issues since last surgery in 2015. But the deep ache pain and shocking pain down arm is gone. I feel the best I have in years. I am no longer taking pain meds. I’ve taken pain meds since 2013. Now my dilemma, what to do next… I personally don’t want to have the second stage (posterior) of this two stage process. One, is because of the horror stories I’ve read about the post op recovery and that it seems people don’t do as well posteriorly as anteriorly from what I’ve read. I don’t want to have a scar on the back of my neck, scar tissue, with more artifact in my neck if I don’t have to. My surgeon says I’m playing with fire if I don’t have the second operation based on my history of 2 failed fusion surgeries. I asked about coming back in 6 months and then if not progressing do the posterior surgery. He says that before any scar tissue can form (if it were to fail) it is best to do now to ensure I am most successful considering my history. He says he could do posterior only after but it would not heal solidly through anteriorly because of the scar tissue. (Anteriorly) He said it may heal around it but can’t grow through it because it is dead scar tissue. Will not be solid construct. My thoughts are what if I wear my neck brace for 5 months instead of 3 months and use a bone growth stimulator? I am also taking vitamin D, magnesium, and calcium tablets. I’m walking everyday. I’m 32 year old female. Could I risk it and be ok. What are my chances? I really don’t want to do the posterior portion of the two stage laid out for me.

Thank you for all of your time

[jefish]

#24544

I guess what I’m getting at Dr. Corenman is how good I’m feeling and I don’t want to go backwards in anyway.

Thank you

[Donald Corenman, MD, DC]

#24554

Don’t blame yourself for the original pseudoarthrosis (“Had incident that occurred that I think led to breaking my fusion”) as it is rare that a patient’s action would cause the non-union.

I’m not a fan of using allograft to repair a non-union as this type of bone graft has less of a chance of obtaining a solid fusion. It also worries me that taking out the old graft at C4-5 caused the C4 vertebra to be very “thinned”. The additional level of C3-4 added to the repair increased the chance of pseudoarthrosis as the more levels added, the higher the non-union rate.

Developing severe radiculopathy after surgery makes me think that the level below could be now symptomatic, the surgery levels did not fuse and are breaking down or there was some surgical area that still had some remaining active nerve compression.

“Black tissue” from an area of metal implants and continued motion (pseudoarthrosis) is almost always from metallosis, a condition where motion between the bone and the metal plate/screws causes metal wear debris and staining of the tissue. There had to be more motion than he thought at this level.

I would assume that your surgeon went back to the allograft technique, took down the nonunion at C5-6 and redid C5-6 as well as adding C6-7. I would agree that you would need a posterior fusion in addition as you have had now two non-unions and a third could be expected. (I hope you don’t smoke or chew as this increases the change of non-union).

You are correct in that posterior surgery in the neck is more discomforting and takes longer to recover but in your case with 4 levels and two prior non-unions, I think you need to insure that all these levels will fuse. The way to do that is with a posterior fusion also.

I understand your reluctance to have this posterior surgery as you are finally feeling better and don’t want the additional surgery. You however will probably go on to a non-union based upon your prior history. Pseudoarthroses can be treated with posterior fusions at a later date and interestingly, can go onto an anterior fusion at the failed fusion level with a posterior fusion. I have repaired about 15 pseudoarthroses in my career with a posterior fusion and all have gone onto anterior fusion eventually. I however don’t recommend waiting and do recommend having the posterior fusion in your particular case at this time.

Taking “vitamin D, magnesium, and calcium” is good but is probably not enough. You might ask your surgeon if he would prescribe “Forteo”, a bone building medication normally used for osteoporosis. I have talked to my colleagues and some of them use it for patients with a history of non-unions.

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.

[jefish]

#24559

Thank you Dr. Corenman for your help…. I really appreciate it. What you do here with this forum is such a wonderful service that you are offering all of us out here that are having such a difficult time. You are truly a blessing and I personally can’t thank you enough.

[Donald Corenman, MD, DC]

#24560

Thanks and keep the forum informed of your progress.

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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