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#6278 In reply to: Neck & Shoulder Pain w/ MRI Results |
Your symptoms are classic for a C7 left radiculopathy from a herniated disc at C6-7. You also have greater occipital neuralgia- most likely from tension at the base of the skull. The C7 nerve compression will cause pain at the top of the shoulder (the trapezius) between the shoulder blades (the thoracic spine) and down the arm into the middle fingers of the hand involved. “Numbness’ and pins and needles will accompany the radiation of pain.
The symptoms should typically get worse with head extension (bending the head backwards) and better with head flexion (bending forward). See website under cervical herniated disc for more information. Many people will get relief by taking the forearm of the affected arm and lying this forearm on the top of the head (the Bakody’s maneuver).
Most likely, the headaches are from irritation of the greater occipital nerve (C2) which originates in the back of the skull and radiates over the head to end right above the eyebrow. There are rare occasions that this C7 herniation can cause these headaches directly but more likely, this is a muscle tension headache that is irritating this nerve from the protective spasm in the back of the neck.
The MRI is classic for this particular disc herniation. “At C6-C7 the patient has a left paracentral disc protrusion, which effaces the anterior thecal sac and abuts the cervical cord. It measures approximately 4 mm anterior to posterior and approximately 1 cn left to right. The AP diameter of the canal is narrowed to approximately 7mm in the region of the protrusion. The protrusion extends about one-third of the way up the posterior aspect of the C6 vertebral body”. This simply means that this herniation is compressing both the left C7 nerve and the left side of the spinal cord.
You do also have some cord compression as noted by the radiologist. Do you have symptoms of imbalance, incoordination or symptoms in any other extremity?
The question is “do you need surgery”? Please read the section under “treatments”- “When to have neck surgery” for more information. Do you have significant motor weakness? This would be the triceps muscle, the wrist flexors (bending the wrist towards the palm) and the MCP extensors (pushing the fingers back against resistance). Can you do a push-up with equal strength on both sides?
If you do not have weakness or signs of myelopathy (see website), you could undergo a program of physical therapy and epidural injections to reduce the pain. This could be a long term successful treatment.
Surgically, you are most likely a candidate for an ACDF or an artificial disc replacement of that level (see website and videos). Because the herniation is compressing the spinal cord, you would most likely not be a candidate for a posterior foraminotomy. Despite what you can read over the internet, lasers are not for spine surgery in my opinion. Lasers burn and vaporize tissue and if they are not perfectly focused, burning of the surrounding structures can occur. A simple visual meticulous mechanical removal of the herniation yields the best and safest results (microdiscectomy before either fusion or disc replacement).
About 65% of my patients travel from out of town to see me. The Steadman Clinic has a routine for patients that travel. If you have any questions, please call my office at (970) 476-1100.
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.Dynamic stabilization does not work. Europe does use it but the studies are poor and the biomechanics are deficient. I have revised many of these devices after failure.
The Dynasys system changes the center of rotation of the vertebra from the middle of the disc to the back of the facets. This causes facet wear and stress. The pedicle screws become loose and this bone-metal motion is also painful. Normal discs that are to be protected by the Dynasys system actually wear out faster.
Again, fusion works for the correct situation. Instability as demonstrated by the L5-S1 level is the perfect situation for fusion. The levels above may or may not need stabilization depending upon the MRI findings and abnormal motion based upon flexion/extension X-rays.
Every patient should have significant consideration and education. Even though I see thousands of patients, each one is taken care of like they were family.
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.I have had periodic back pain episodes dating back 20 years or more, they were often intense in lower back area, but short-lived (OK within a day or so of rest/stretching, etc.). About 9 years ago, my back started to stiffen considerably in the L3 – S1 zone, but P/T seems to have dealt with that pain to a reasonable level (now background 1 – 2/10 pain for that aspect).
The current sharp, stabbing & burning radiating pain is recent (last several months) and is more intense (7 to 8 out of 10 on the pain scale). That particular pain is relieved by sitting or flexing forward. Walking is difficult when the pain events are at their highest levels, running or anything more than that impossible.
The majority of the pain (~80%) seems related to the radiating symptoms down my glutes and hips, and the remainder is lower back pain.
Standing after sitting always increases the radiating pain, and usually I cannot walk until I stretch & try to get the back calmed down a bit. I am wearing an over-the-counter back brace that seems to help somewhat when walking & doing my P/T workouts. My lower back pain (20%) does not change much whether sitting or standing, but does decrease after P/T workouts, particularly stretching/core exercises. The radiating pain moderates as well, but to a much lesser degree and for less duration.
I sleep relatively pain-free with a pillow under my knees positioned on my back. I can also sleep on my sides just fine, but cannot sleep on my stomach without pain.
I have stopped all activities that cause increased pain. As I mentioned above, I can ride a bike still and do my P/T workouts, but that’s about all. Swinging a golf club softly often relieves some pain, but walking the course causes pain, so I’ve stopped that too. My regular activities when not pain limited include skiing (water & snow), snows boarding, snow skiing, snow & water kiting, mountain biking, running, tennis, golfing, hiking and other related outdoor activities.
My treatments have been P/T over the last 6 years, and injections over the last two. I have had 4 facet injections over 2 years, 1 of which moderated pain for 1.5-months, but the other 3 had no effect. I had two epidural injections over the last two weeks (1st put in around L3/L4, 2nd at L5/S1), each had pain benefit for a day or two, and the radiating pain has returned to its prior levels.
Thank you so much for the thoughts and advice!
#6263Topic: Non-fusion options for spondylolisthesis & related lumbar issue in forum BACK PAIN |Dear Dr. Corenman:
I am writing you in hopes that you may be able to direct me to what you consider the best potential non-fusion treatments (in your view) now or in the near-future for spondylolisthesis, stenosis & bulging/herniated disks in the lumbar spine. I am a patient with those issues and don’t believe fusion is the right course for me given my age (52) and activity level (highly active), but fusion is recommended by most surgeons I’ve spoken with. But what I read in NLM publications, fusion has iffy benefits over the long-term. I am feeling great trepidation as to my physical future that comprises such an important part of my life, health and my family’s. Any thoughts or direction would be very appreciated.
As I understand my diagnosis from MRI’s & x-ray evaluations, these are the problems I have in my lower back:
1. Degenerative Disc Disease: [L3/L4] [L4/L5] [L5/S1] Bulge/Herniations with moderate disk height loss
2. Spinal stenosis: [L3/L4] T [L4/L5] [L5/S1]
3. Foraminal Narrowing: [L4/L5] Abut [L5/S1] Abut [L3/L4] L [L4/L5] [L5/S1]
4. Facet Disease: [L3/L4] [L4/L5] [L5/S1] – L4/L5 noted as severe facet hypertrophy and L5/S1 noted as severe & extensive facet hypertrophy
5. Spondylolisthesis: L5/S1, with 9mm anterior displacement. That slip was 3mm 2 years ago on a prior MRI.So, I guess you could say I’m one of the lucky ones in having the kitchen sink of issues. I am very healthy otherwise, but the pain, particularly the radicular symptoms, is becoming debilitating. I have done aggressive P/T for years (the problem has persisted over the last 9 years), and my P/T advisor said there is nothing further they can do, although I know there are always additional options that might assist (I’m looking into those now). I have tried chiropractors and active release therapy (ART) as well. I have had several facet cortisone injections over 2 years (1 out of 4 had a moderate pain reduction for 1.5-months, followed by a full return of symptoms). I had a diagnostic facet nerve block that made my mid-back feel somewhat better, but did nothing for the lower back & gluteal pain.
Friday May 18, I had an epidural injection. Pain moderated on Saturday for the day (down from 7/10 to 4/10 pain), but returned Sunday & Monday on the same pain cycle. It felt like the epidural just did not get down to the L5/S1 area, maybe because of stenosis and disk blockages, or maybe it just had no effect. At this time, the primary pain of concern is radicular, the 2-3/10 pain in my back is incidental and I can live with that. I had a followup block put in at L5/S1 yesterday. There was physical pain during the injections that ran down my butt & leg. I take that as a good sign in that it must have been into an area of impingement, and for at least today (Saturday), my pain is down to 3 from 7 or 8.
Several surgeons have recommended variations of thermal ablation, decompression, laminotomy, discetomy and fusion. Fusion is the most recommended component with the others. Because of problems at several disk levels, the fusion is recommended S1 – L3. My limited understanding from my readings is that this will incapacitate me relative to my active lifestyle, and most likely over the long term cause related problems in my thoracic region. In short, fusion does not present good enough clinical results over the long-term relative to my own likely longevity.
Any thoughts or direction would be very much appreciated. It seems the USA is a bit behind the rest of the world in back treatment options absent fusion. I am looking for a doctor here who might have different recommendations/options.
I have a copy of my x-ray & MRIs if that would be useful for your consideration.
Best regards, and thank you.
#6247 In reply to: operation fusion |You have to ask yourself what the fusion is going to do for you. First- where is the pain coming from? This requires you to describe your pain. Is it pure lower back pain or is there a component of leg pain? If so, what is the percentage of leg pain vs. lower back pain? Do you have more of one vs. the other?
The reason for these questions is you have to define what you are treating. If you had mainly leg pain and had a new disc herniation causing nerve compression and previously had only one surgery at this level, you would probably be a candidate for another simple decompression.
If you had mainly back pain and a fusion is recommended- what was the work-up that led to the decision for fusion? What do the surrounding discs look like? Is there instability based upon X-rays (flexion/ extension)? Was a discogram performed to determine the pain generator (see website for details)?
There are many unanswered questions.
Let us accept that you need a fusion of L5-S1 and this is the only pain generator. The success rate for a one level fusion performed correctly is about 90% for 2/3 relief of pain.
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.You underwent a microdiscectomy at L4-5. I assume that your leg pain abated but you have continued lower back pain. Did you go through an extensive rehabilitation program? That would be my first recommendation. Core strengthening is important.
Yes NSAIDs can be nephrotoxic and hepatotoxic but the incidence of those complications is very limited and can be recognized by lab tests. Normally- stopping the medication resolves the issues. If NSAIDs work for you, consider taking them.
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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