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#33117Topic: Cervical ACDF non union in forum NECK PAIN |
In Aug 2019 I had ACDF C4-C6 because I was having pain and loss of strength in my arm and hand. Recovery went pretty well although I had some swallowing problems for about 3 months (it did help me lose 25 lbs though). I’ve been walking 1.5-4 miles a day and felt good until June 2020 when I started having severe shoulder blade, neck, arm, and forearm pain. PT including dry needling, gentle manual traction, and strengthening helped for about 3 weeks. One day I woke up with neck pain again and the inability to do any of the strengthening exercises for my arm/shoulder without increased pain.
Physiatrist took xrays including extension and flexion where he saw movement with C6 and what looks like lack of bone. He referred to it as a nonunion and mentioned that a bone stimulator might help but wanted to order MRI and check C7 status.
Updated MRI results are below:
C1-C2: The atlantodental interval and lateral atlantoaxial articulations are normal.
C2-C3: No evidence of disc herniation. Mild bilateral facet arthrosis. No central stenosis or neural foraminal narrowing.
C3-C4: Disc bulge with desiccation. The bulge produces mild central stenosis, narrowing the anteroposterior dimension of thecal sac to 9 mm. Mild bilateral facet arthropathy and uncovertebral hypertrophy produce mild bilateral neural foraminal narrowing, right greater than the left.
C4-C5: Surgical level. No central stenosis. Hypertrophic changes of the facets produce mild to moderate bilateral neural foraminal narrowing.
C5-C6: Surgical level. No central stenosis. Hypertrophic changes of the facets produce mild neural foraminal narrowing.
C6-C7: Right paracentral disc protrusion with disc desiccation. The extrusion produces central stenosis, narrowing the anteroposterior dimension of the thecal sac to 7 mm. Moderate bilateral facet arthropathy and uncovertebral hypertrophy produce moderate bilateral neural foraminal narrowing.
C7-T1: No evidence of disc herniation. Mild bilateral facet arthosis. No central stenosis or neural foraminal narrowing.
1. Can bone grow after 14 months? Is it likely?
2. If surgery is recommended, what needs to be addressed?
3. Are there different ways of addressing the issues surgically?
4. Can you see a nonunion on an MRI?Thank you so much for your site and for helping people understand their spine issues so they can make informed decisions.
#33110Topic: Lumbar facet pain? in forum BACK PAIN |Hi. My history includes two discectomies at L5/S1, and a fusion at L5/S1 a couple of years ago. I’m doing fine from those. However, about six months ago, I began having deep pain in my left low back that radiates into buttocks and a little into posterior thigh that is:
-worse with extension,
-relieved by flexing forward and to the other side,
-worse with sitting/driving,
-initially relieved with walking but worse with long walking (>0.5 mile),
-makes sleeping difficult,
-doesn’t hurt when I cough or sneeze (like all my disc issues did)I also took a round of steroids for an allergic reaction, which helped my back A LOT for about a week. I have had other periods without pain sort of out of nowhere, but then it flares up. I have had an MRI, which doesn’t show anything compressing or any problems with my fusion hardware. I had an SIJ injection, which did not help me at all. It actually flared up the pain for a while but I never got any benefit.
I’ve been seeing my neurosurgeon for this, and he has told me to take anti-inflammatory medications (Mobic), which I’m just starting, and that it must be some kind of inflammation. It seems to me that this could be facet syndrome of my lumbar area. A couple of questions:
-Does it sound like possibly facet? I’m only 38 years old but used to be an ultra marathon runner (many thousands of miles on my back)
-Would this most likely be the facet joint ABOVE my L5/S1 fusion (I’m assuming the fusion would keep the facet from being inflamed?)
-Is my best bet to go to a reputable pain management physician instead of my surgeon?This pain is really affecting my quality of life and ability to sleep/do what I want. Thanks for your help!
#33090 In reply to: 3 Weeks Post Microdiscectomy Pain |Hi Doctor. I have received my pre surgery and post surgery MRI reports. Can you please assist with interpreting these for me? The good news is my back is starting to settle back down. I’m not feeling 100% as I did before my fall 2 weeks ago but things are starting to normalize.
1. What is your overall takeaway from the pre and post surgery findings?
2. Does it appear I have reherniated?
3. I see that I still have a protrusion at L4/L5 post surgery. Is this normal? If so and if I practice proper spinal movements going forward, is it likely for the protrusion to shrink in size over the next few years?
4. The fall I had off the tree 2 weeks ago made me feel “sick in the back” along with over symptoms like numbness in the legs. You noted this might be due to annular torque that I caused when landing. Is this possibly the “annular fissure” noted on the post surgery report? If so will the annular fissure repair itself over time assuming I practice proper spine hygiene?
5. Should I be concerned regarding the thoracolumbar levoscoliosis?
PRE SURGERY
FINDINGS:
Mild partial disc desiccation from T10-T11 through L3-L4 and to a greater degree at L4-L5.
At the L4-L5 Leve mild posterior bulging and 4mm broad posterior left paracentral protrusion is seen. Moderate ligamentum flavum hypertrophy noted. Mild to moderate compression of the thecal sac to a more marked degree in the subarticular lateral recess on the left at the origin of the left L5 nerve root sleeve.
Slight annular bulging at L2-L3 and L3-L4
2mm left posterior protrusion mildly indents the anterior margin of the thecal sac at L1-L2
IMPRESSION:
At L4-5 minimal bulging and moderate broad left posterior protrusion as well as some ligamentum flavum hypertrophy bilaterally. Mild to moderate compression of the thecal sac to a more marked degree in the subarticular lateral recess on the left at the origin of the left L5 nerve root sleeve.
POST SURGERY
FINDINGS:
Mild long segment thoracolumbar levoscoliosis is seen with a Cobb angle at 10 degrees and leftward apex about L3-L4.
Straightening of the normal lumbar lordosis without significant listhesis.
No acute fracture, compression deformity, or frank aggressive osseous lesion.The conus medullaris terminates normally at T12-L1.
A 5mm T2 hyperintensity in the right kidney is too small to characterize but generally lacks enhancement favors a small renal cyst.Disc desiccation L4-L5 with mild disc height loss. Small Schmorl’s nodes are present centrally in the endplates throughout the lumbar region.
Evaluation of the individual lumbar demonstrates:
L1-L2 Left paracentral annular fissue up to 9mm with a left paracentral disc protrusion to 3.5mm. This encroaches on the left lateral recess without nerve root contact. No overall thecal sac stenosis. No neural foraminal stenosis.L2-L3: Unremarkable
L3-L4: Unremarkable
L4-L5: Prior L4 hemilanminectomy since 4/3/2020 for disc resection L4-L5. Disc encroachment on the central zone and lateral recesses has significantly improved since the prior exam. There is a posterior central/left paracentral annular fissure identified up to 12mm in with associated with a 4.5mm posterior central/left paracentral disc protrusion. Disc material encroaches on the left greater than right subarticular zones near the descending L5 nerve roots but without clear contract or mass effect. The thecal sac is narrowed to 9mm at the AP midline with prior caliber 6mm. Mild bilateral foraminal stenosis without exiting nerve root contact.
L5-S1: Unremarkable.
IMPRESSION:
1. L4-L5: Interval L4 hemilaminectomy since 4/3/2020 for disc resection L4-L5. Disc encroachment on the central zone and lateral recesses has significantly improved since the prior exam.
There is a posterior central/left paracentral annular fissure identified up to 12mm in with associated with a 4.5mm posterior central/left paracentral disc protrusion. Disc material encroaches on the left greater than right subarticular zones near the descending L4 nerve roots but without clear contact or mass effect. The thecal sac is narrowed to 9mm at the AP midline with prior caliber 6mm.
Mild bilateral neural foraminal stenosis without exiting nerve root contact.
2. L1-L2: Left paracentral annular fissure up to 8.5-0mm with a left paracentral disc protrusion to 3.5mm. This encroaches on the left lateral recess without nerve root contact or thecal sac stenosis.
3. Mild thoracolumbar levoscoliosis with straightening of the normal lumbar lordosis noted.#33086 In reply to: Please help me understand my MRI report |Hi Dr Corenman …
Here is a recent MRI report are you able to interpret this to me please and much thank you..
Brain
Clinical Indication…headaches…follow up syrinx
Compare to May 6 2019
No abnormal focus of diffusion restriction
No Blooming low signal intensity focus on the gradient echo sequence to suggest hemosiderin deposition
No hydrocephalus ..the the ventricular system , convexity sulci , and basel cisterns are intact
aside from a solitary deep periventricular high signal intensity focus right frontal lobe , series B image 20 which is stable compared with previous , no high signal intensity foci within white matter…
Major arterial end venous flow voids are intact
craniocervical junction is intact
ON T1-T2 …within the subcutaneous tissue , left parietal region , there is a subcutaneous lesion measuring 11 mm … This was present on previous ..This should be clinically apparent and could represent a sebaceous cyst and correlation required
Summary
cause for headaches not seen ..Essentially normal MRI of Brain with no significant change compared to priorMRI Cervical Spine
compared to Dec 11 2019
Cranial cervical junction in tact
At C5-6 there is a generalized posterior osteochondral bar with a more focal central component ..CSF remains interposed between the osteochondral bar and the spinal cord ..Moderate narrowing right foramina and mild narrowing left neural foramina
The cervical spinal cord is preserved
Prominence of the central canal/thin syrinx is noted to extend from approximately level of the C3-C4 disc space crudely to approximately the level of the C6-C7 disc space ..No cord expansion of cord edema
summary
stable prominent central canal/tiny syrinx
posterior osteochondral bar C5-C6#33083 In reply to: Cervical pseudoarthrosis |MRIs are performed in the lying down position so gravity is not part of the equation. This is why X-rays, especially flexion/extension views are equally as important.
Your CT report notes; “C4-C6: Postop C5 vertebrectomy. The prevertebral plate and bilateral C4 and bilateral C6 screws are in good position and intact. No hardware fracture or loosening. Anterior interbody cage extends from inferior C4 through superior C6. Lucencies are seen within the bone graft within the cage on both the sagittal and coronal reformatted images, indicating nonunion. No cord or nerve root compression at C4-C5 and C5-C6.
This indicates the surgery (C4-6 with C5 corpectomy) was successful at decompressing the spinal cord and nerve roots but the graft never went on to incorporate and you never achieved a fusion. The C6-7 level needs to be addressed (“C6-C7: Degenerative disc disease and spondylosis. Left posterior lateral foraminal disc extrusion. Flattening of the left anterior cord surface. Slight reversal of the cervical lordosis”) indicating both deformity (kyphosis) as well as cord compression.
Generally, a corpectomy level that did not fuse needs to be addressed with a posterior fusion and since a posterior approach needs to be done at C4-6, the C6-7 level can be included with a decompression and fusion.
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.#33068 In reply to: S/p TLIF 8 weeks ago-new sx |There was no obvious comment about degenerative facet changes at L4-5 but sometimes, radiologists might not pick up on that. The best way to determine if that slip is significant is with flexion/extension X-rays.
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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