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I forgot to ask during my previous post, for pseudarthrosis at T1/T2 would medial branch blocks be the best option to diagnose if this level is causing pain, and dynamic MRI or flexion/extension x rays at this level is worth trying? Thanks again

Good morning Dr. Corenman
well I had an MRI completed last month after in office Xrays revealed something the Dr. saw. I met with the Dr yesterday and we really did not over the results, he just said i re herniated and needed a fusion. Then had me take more xrays in the office. Once he looked at those he said fusion would be the way to go as the space is collapsed? Here is what i can see on the written report:
Transitional anatomy is seen at the lumbrosacral junction with L5 sacralized on the left and either sacralized versus partially sacralized on the right. The caudal most disc space will be labeled L4L5, similar to the convention used on prior MRI from 09/19/2019. Confirmation of spinal numbering/anatomy would be advised prior to any planned intervention.

Postsurgical changes are seen to the left of midline at L4-L5 presumably from prior disc resection
Correlate with the specifics of the patient’s surgical history.

Lumbar alignment is preserved There is no significant listhesE. Thoracolumbar levocurvature is
seen without scoliosis by criteria.
No acute fracture, compression deformity, or frank aggressive osseous; lesion Small intraosseous
hemangiomas are noted.

The corms medullaris terminates normally at L1-L2.
T2 hyperintensites are seen in the lower kidneys suggestive of renal cysts.

There is disc desiccation with moderate disc height loss L5-S1 including discogenic endplate
changes. The remaining intervertebral disc heights and signals are preserved.
Evaluation of the individual lumbar Levels demonstrates: Ll -L2:Unremarkable.

L2-13: Unremarkable.

L3-L4: Mild left greater than right faucet arthrosis. Trace facet effusion on the left possible.
Otherwise, unremarkable.

L4-L5: Granulation tissue is seen in the left lateral recess, though evaluation with post-contrast
MRI may be helpful for further assessment.
A posterior central disc extrusion is present spanning 12 mm in craniocaudal extent tracking below
the level of the disc space measuring up to 10.5 mm in AP dimension and over 14mm transvers.
‘This narrows the thecal sac to 9 MM and encroaches on the subarticular zones likely contacting the
bilateral descending L5 nerve roots (series 7, images 27-29). Mild left greater than right facet
arthrosis with a left-sided facet effusion and 4-5 mm synovial cyst also projecting into the left
subarticular recess contacting the descending left L5 nerve root, new since 09 /19 /2019.
Mild right and moderate to severe left neural foraminal stenosis “with a foraminal disc bulge near
the exiting right L4 nerve root and a left foraminal disc protrusion up to 4 mm contacting the
exiting left L4 nerve root.

IMPRESSION:

1. Transitional anatomy again seen at the lumbosacral junction with the caudal most disc space
labeled L4-L5. Confirmation of spinal numbering anatomy would be advised prior to any planned
intervention
2. Postsurgical changes are seen to the left of midline at L4-L5 presumably from prior disc
resection.
Correlate with the specifics of the patient’s surgical history.
3. L4-L5: Granulation tissue is seen in the left lateral recess , though evaluation with
post-contrast MRI may
be helpful for further assessment
Posterior central disc extusion tracks below the level of the disc space measuring up to 10.5 mm
in AP.
My other question is this. He said he would go through my abdomen and then two small holes in my back? is this considered Anterior? which is fine, but i am curious if my having 3 c-sections and one abdominal hysterectomy is a problem? i hope not as i have heard you heal faster going through the front. I am not sure how i feel about all of this just yet, but i do want to feel better and get back to life. Do you think in your opinion this is the best and/or only way to go to get relief and back to somewhat normal? thank you again for your time. I truly value your input .

Dr. Corenman,

Here are the results from my MRI taken May 27, 2020, the surgeon said that the MRI is showing everything looks good and that sometimes the nerve just takes a longtime to heal and continue PT…I continue to be in pain daily wondering if this nerve will ever heal. I am two and half months post-surgery, he says it still early in the recovery process. My MRI results are;
Examination: MRI LUMBAR SPINE W/WO
Indication: BACK PAIN, LOW. L4-5 microdiscectomy 3/17/2020
Technique: MRI lumbar spine without and with intravenous contrast.
Comparison: Lumbar spine MRI 2/18/2020
Findings: At L3-4, there is a mild disc bulge and superimposed left foraminal disc protrusion. No spinal canal or foraminal stenosis.
At L4-5 there are postoperative changes on the left from recent discectomy. There is enhancing granulation tissue in the left epidural space surrounding the left L5 nerve root sheath. No recurrent disc herniation is appreciated.There is no spinal canal or neural foraminal stenosis. There is a minimal 5 mm fluid collection at the laminotomy site. There is slightly increased size of a mild Schmorl’s node of the L5 superior endplat with mildly increased adjacent Modic type I endplate Change.
At L5-S1 there is an unchanged mild disc bulge. There are intraforaminal and far lateral disc osteophyte complexes bilaterally. There is moderate/severe right foraminal stenosis. No left foraminal stenosis.
There is T2 STIR hyperintense edema of the left paraspinal muscles which are beginning at L5 through visualized sacrum.
Impression:
Postoperative changes at L4-5. No recurrent disc herniation appreciated.

So I’m still dealing with this chronic neck pain issue. Just to recap, the symptom appears to be sore achy muscles on both sides midway to lower part of the neck on both sides but most pronounced on the right. Pain is lowest in the morning and worst at night. In general pain is lower when lying down than sitting/standing. Muscle relaxants/NSAIDS/Oral Steroids do not relieve the pain. Palpating of the neck muscles as well as the tops of shoulders feel tender.

I went to another PM doc last summer and he sent me for a SPECT-CT which the results are below. His view was that if the issue was facet or even disc related, something would show on this test. The test did not show any abnormal uptake in the cervical spine. Based on the test, the PM doc was thinking the issue is purely muscular in nature and wanted to start with trigger point injections into the neck. I decided to hold off on that treatment because I had previously had TPI in the tops of my shoulders from another doc and they did nothing to help. Does the SPECT-CT shed any additional insight into a possible cause of my pain? The only other thing I noted in the scan was the additional uptake in the AC joints.

TECHNIQUE
A total body bone scan was obtained in standard projections with additional views obtained of the
cervical, ribcage and skull. SPECT CT images of the cervical in the standard projection were
performed. A low dose attenuated CT scan was obtained for localization purposes.
CT was performed with one or more of the following dose reduction techniques: automated exposure
control, adjustment of the mA and/or kV according to patient size, or use of iterative
reconstruction technique. Total DLP (mGycm)= 109

COMPARISON
No comparisons

TOTAL BONE SCAN FINDINGS
The total body bone scan shows multiple patchy areas of increased activity seen throughout both
sides the ribcage, both sides the mandible left greater than right as well as the right
supraorbital region. Rest of bone scan shows some activity involving the AC joints. Both kidneys are identified.

TOTAL BONE SCAN IMPRESSION
1. Abnormal bone scan showing multiple areas of osteoblastic activity seen throughout both sides
the ribcage. The patient gives no history of trauma. This are indeterminate could related to
old remote trauma and or if the patient had no trauma than pathological etiology would have to be
consideration. This may need further clinical evaluation
2. There is increased activity involving both sides of the mandible left greater than right
consistent with periodontal disease
3. Focus of increased activity involving the right supraorbital region of the skull.
This indeterminate. May need further clinical evaluation.

SPECT CT SCAN FINDINGS
The SPECT scan shows no abnormal areas of increased activity seen involving the cervical spine
particular the articulating facets or posterior elements

There is intense activity seen involving the left side of the mandible posteriorly as well as the
right side of the mandible also posteriorly.

The rest of the SPECT scan localizing images show no bony lesions identified. Upper lung zones
that are imaged appear normal. There is no adenopathy identified.

SPECT CT SCAN IMPRESSION
1. Coronal SPECT CT of cervical spine
2. There is significant activity involving both sides the mandible posteriorly compatible with
periodontal disease. Oral dental evaluations advise
3. No addition pathology otherwise