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  • Tom
    Participant
    March 22, 2020 at 8:42 pm
    Post count: 4
    #32348
    Topic: MRI / Image Review — Moderate Chronic C8 Radiculopathy in forum NECK PAIN |

    Hi Dr. Corenman,

    I’m a male in my early 30’s and was in a rear end accident over two years ago — 60mph impact.  I’ve had intermittent dull aches in my right thoracic spine as well as frontal left shoulder aches (which had a grade 1 AC separation) and clicks/pops all the time.  

    My initial cervical & thoracic MRIs taken 3 weeks after the accident showed the following — cervical rather normal, thoracic a bit more problematic.
    Cervical: C3-C4 C4-C5 C5-C6 Broad Based 1mm posterior disc protrusion.  AP diameter 12mm.  All other levels normal.
    Thoracic:  T3-T4 Broad Based 1mm protrusion, T5-T6 Right paracentral/lateral 3mm protrusion mildly indenting the ventral surface of the spinal cord (no cord edema present to suggest acute compression).  Mild right lateral recess narrowing.  T7-T8 Left lateral 2mm disc protrusion, 12mm canal

    In August 2019 my thoracic spine started clicking when breathing and got me all concerned, so I visited a chiro to see if an adjustment would help. While it was my 8th or 9th chiro visit within the last 2 years, when he was adjusting my neck I somehow flinched and resisted the HLVA technique. No audible pops, just muscle tension.  No pain at the time, but quite unsettling.  

    Coincidentally, I had an EMG scheduled prior to this incident in order to discover if there was any nerve disfunction affecting my left shoulder, which took place 3 weeks after the chiro accident.  Between the chiro visit and EMG study, I began experiencing electric-like shock symptoms on the left side of my neck — sometimes localized to the nape of my neck, sometimes radiating across my trap.  The EMG study revealed Moderate Chronic C8 radiculopathy on the left.  In reviewing this study with my Ortho, he ordered an CTA Chest with contrast and an MRI Brachial plexus to rule out any plexopathy related to my thoracic outlet syndrome.  Both studies were negative.

    I went through over 12 weeks of physical therapy, and continue to do so to this day but things still haven’t resolved.  I visited a pain doc last month who ordered another MRI.  That report showed:
    C3-C4 posterior 2mm bulge, Mild uncovertebral hypertrophy.  
    C4-5 Minimal posterior bulge.
    C5-6 Minimal bulge with mild uncovertabral hypertrophy.  C6-7 no significant bulge.  
    C7-T1 Left paracentral shalloow disc protrusion measuring approximately 1.6mm AP.  This measures approximately 5.2mm transversely.  This mildly effaces the ventral thecal sac.  This may contact the ventral nerve rootlet on the left.  No significant spinal canal stenosis.  No significant facet joint arthropathy or foraminal narrowing.
    At the T1-T2 level, there is a ventral disc osteophyte complex.

    I’m curious what the “5.2mm transversely” means.  Here is an image of my C7-T1 if you can offer an opinion:
    null

    Epidural Steroid Injections were scheduled for 3/13, but I cancelled due to concerns of side effects and didn’t want to dampen my immune system during this pandemic.  I’m not opposed to ESIs if necessary, but reading about their inability to correct the core problem leaves me with little hope that I could benefit from them.  I’ve looked into alternative procedures like Regenexx’s PL-Disc Platelet Lysate epidural as well and am leaning more that way if anything.

    In the early stages of this shocking symptom (7 months ago), I didn’t monitor my activity heavily to avoid this shocking pain — I was more busy trying to see what my limits were and what made it happen so I could tell doctors.  Working under my car with awkward arm and neck positions, etc.  Heck, just 2 weeks ago I tried to go indoor rock climbing thinking I could manage and re-aggravated it all over again.  The pain isn’t in any way constant, it comes and goes.  Doesn’t happen when I sleep.  No paresthesia.  Symptoms are not aggravated by spurling/compression test.  Perhaps the most consistent motion that exacerbates it is when I try to nerve glide (both arms out, right hand down, turn my head to the right and ZING!)

    While we’re on lock-down, I am really focusing on improving non-operatively — at-home traction, natural anti-inflammatories, better diet, PT exercises that DON’T aggravate, and I even have a posture-pump in attempt to restore my neck curve and release tension.

    Would love your opinion on the chiro incident and if I should be on the lookout for anything else that it may have caused.  Its my opinion that the rotational torsion of my neck (with me resisting) is what caused the disc bulge, given the difference in MRI findings and timing of the onset of symptoms.

    In your opinion, do I have any hope of spontaneous regression or lessening of the pressure on my ventral C8 nerve root through conservative treatment?  Is surgery a likely outcome in my case?  

    Sorry this was so long — just lots on my mind. I really appreciate any insight & help you’re able to provide.

    Sincerely,
    Tom

    Meri
    Participant
    March 21, 2020 at 12:17 am
    Post count: 4
    #32338 In reply to: Lumbar Radiculopathy -MRI result inconsistent with symptoms |

    Thank you again as your advice has been some of the most accurate that I’ve received.
    I did have an L4-5 TLIF on 6/19/19. Since then, there has been almost no change in my symptoms which are still sometimes worse at night (lateral leg/foot pain, foot burning and pins and needles to numbness of the left foot. The same triggers like standing, sitting for more than a few minutes, and walking on concrete all exacerbate the pain as they did prior to surgery.
    I’m told that because I was compromised for almost 2 years prior to Worker’s Comp approving the surgery that it just may take time for the pain to resolve. At my follow up in November, I was told that another MRI was to be ordered with continued PT. My comp company denied payment for both, so I’ve continued the prescribed PT routine as tolerated and I just paid out of pocket for another upright MRI with results pending.

    Is continued pain, in your experience, common or potentially chronic in cases such as mine? It was also suggested (again) that it may be my Piriformis muscle, but I have trouble believing that as the symptoms seem like they’re still nerve root related and there is nothing at all that alleviates it including narcotics, NSAIDS, gabapentin, CBD/THC, or a TENS unit. I had hoped that surgery was going to resolve this.

    Thank you,
    Meri

    Donald Corenman, MD, DC
    Moderator
    March 16, 2020 at 9:59 am
    Post count: 8660
    #32303 In reply to: Back and hip pain returned 2 months after discectomy |

    Advancing pain could be from increased inflammation due to greater use of your leg, hematoma/seroma, infection. mechanical deformity and recurrent herniation. You have been ruled out for infection (labs). Your symptoms don’t really match with facet syndrome as your pain is “some sharp pain when bending down and to the left” where normally, facet pain occurs with extension, the opposite of your complaint.

    That leaves inflammation (seroma-most likely) or recurrent disc herniation. Your current examination would be helpful. Any change in motor strength or significant increase in particular findings (SLR, increased area of numbness) could indicate a recurrent disc herniation. Your doctors advice “take naproxen twice a day for a week and begin physical therapy” is a good first start. If you don’t start to see improvement, a new MRI soul be helpful.

    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.
    Donald Corenman, MD, DC
    Moderator
    March 14, 2020 at 11:46 am
    Post count: 8660
    #32279 In reply to: Cervical Questions |

    You note “pin and needle pain in my hand usually felt in my thumb first then the pointer, and middle finger” and then “pain in my neck primarily on the right side, right shoulder muscle tightness that goes down to the shoulder blade, this radiates to close to my armpit in the shoulder and down the right arm with majority of the shooting/somewhat sharp pain to my elbow”.

    Your symptoms are consistent with a C6 or C7 radiculopathy. The symptoms noted “The neck pain and headaches are aggravated by anything overhead” could be from tilting your head back (extension) which is normally associated with overhead work and associated with cervical radiculopathy (pinched nerve in the neck) but can be associated with thoracic outlet syndrome.

    See: https://neckandback.com/conditions/symptoms-of-cervical-nerve-injuries/
    https://neckandback.com/conditions/radiculopathy-pinched-nerve-in-neck/ and
    https://neckandback.com/conditions/thoracic-outlet-syndrome/

    Your MRI notes “mild to moderate bilateral neural foraminal encroachment and at least mild central canal stenosis” at almost every level so this confirms the symptoms could be from nerve root compression but does not specifically identify the level or levels involved.

    I think the next step is a very thorough physical examination to determine if one or two roots can be identified. Most likely the C6 and C7 roots. Then a selective nerve root block with a pain diary would be used to “drill down” to the suspected root(s) involved. Then depending upon your structural anatomy, an ACDF or an ADR can be used to treat this condition surgically. See:

    https://neckandback.com/treatments/epidural-injections-and-selective-nerve-root-blocks-diagnostic-and-therapeutic-neck/
    https://neckandback.com/treatments/diagnostic-therapeutic-neck/
    https://neckandback.com/treatments/pain-diary-instructions-for-spinal-injections-neck/
    https://neckandback.com/treatments/anterior-cervical-decompression-and-fusion-acdf/
    https://neckandback.com/treatments/artificial-disc-replacement-adr-for-cervical-spine/

    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.
    Donald Corenman, MD, DC
    Moderator
    March 14, 2020 at 10:44 am
    Post count: 8660
    #32275 In reply to: Pitched nerve c5/6 |

    I will assume that you had good relief from your first surgery 4 years ago and had no residuals such as triceps weakness. New foraminal stenosis at C5-6 will compress the C6 nerve which goes to the biceps muscle and the wrist extensors (pulling the hand back). C6 can occasionally affect some types of grip but grip strength is generally considered the C8 nerve (C7-T1 level).

    Decompression from behind is acceptable for foraminal stenosis but if the compression is from uncovertebral hypertrophy (from the front-not the back of the spine), the surgery is not as effective.

    You can try epidural injections or even oral steroids but you might need surgery with the weakness you exhibit (however, make sure you confirm the weakness is generated by a C6 nerve problem which is still to be determined).

    https://neckandback.com/conditions/radiculopathy-pinched-nerve-in-neck/
    https://neckandback.com/conditions/symptoms-of-cervical-nerve-injuries/

    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.
    Mindy1198
    Participant
    March 10, 2020 at 4:18 pm
    Post count: 1
    #32261
    Topic: Cervical Questions in forum NECK PAIN |

    Hello Dr. Corenman,

    I have had pain in my neck primarily on the right side, right shoulder muscle tightness that goes down to the shoulder blade, this radiates to close to my armpit in the shoulder and down the right arm with majority of the shooting/somewhat sharp pain to my elbow. I have pin and needle pain in my hand usually felt in my thumb first then the pointer, and middle finger but tends to increase as it continues to tingle.
    I have headaches that start at the base of my skull and move forward as it intensifies, its a constant headache with no shooting or sharp pain just a constant pain that starts dull and gets more intense throughout the day. The neck pain and headaches are aggravated by anything overhead. I used to participate in Crossfit but have since stopped as it was irritating my symptoms. Now I go to a regular gym and avoid anything overhead but still have intensified pain with upper body exercise.

    Percentage of pain by location 50% neck & headaches 40% shoulder 20%arm.

    Pain intensity varies: Daily 4-6 in the neck. Daily Headache 3-5. Daily Arm pain 2-4. Neck and head pain close to once a week gets to about a 9 with arm getting to about 6.

    Weakness: General over head press weakness but I’m not sure if this is strictly due to avoidance from pain.

    Incoordination and Numbness: None

    Onset and Length of Time Symptoms Have Been Present:
    Pain started about two and a half years ago, was very active in Crossfit, Gymnastics based classes, and Running. Symptoms started with neck pain, shoulder and headache. Arm pain became increasingly noticeable over a month or so while visiting chiropractor.

    No injury.

    Had previous compression fracture of the C5 from a water skiing accident in 2005. Causing extreme headaches and burning down my whole right arm and hand. Completed therapy, steroid injections, and work neck brace for 8 weeks. Problems subsided.

    Activities:
    Lifting heavy at the gym aggravates symptoms sometimes causing an intense headache generally squatting or leg press.
    Biking for 8-10 miles irritates neck and arm pain.
    Laying down on heating pad can curb the neck and shoulder tightness but does little for the arm pain and headache.
    Generally I wake up in pain and the pain intensifies over the course of the day and builds over days.

    Pain Intervals:
    Daily pain that can range from annoying to debilitating.
    2 pain level / annoying pain days are rare but celebrated, and I intentionally will not go to the gym or anything that might cause an increase.

    Activity and Occupational Restrictions:
    Pain has changed my life a great deal, I have went from highly active in different activities to two days a week at the gym with modified lifting.
    I have a management / 80% desk job with no physical demands but walking.
    I have missed work around 1-2 days a month due to pain and headache intensity.

    Previous Consultations or Treatment:
    I have been seeing a Neurologist for about 2 years primarily treated for Migraines – Clear Brain MRI results and normal EMG results. Currently getting monthly Amovig shot and Botox with no improvement.
    2018 was visiting a Chiropractor, some headache improvement but no help with arm and shoulder pain.
    I have had Physical therapy for 12 weeks unsuccessfully causing increased pain.
    Acupuncture down right side of neck, shoulder and arm. No results.

    Neurologist currently seen, indicated my MRI results were normal from the radiologist report.

    MRI completed on 2-21-2020
    Report:
    Indication/History: History of headaches neck pain. History of stiffness radiating down right arm:

    Procedure: MRI cervical spine without contrast

    Comparison Plain film cervical spine performed 5/17/2018

    Findings:
    STIR sequences demonstrate no focal height loss or diffuse marrow edema.

    There is diffuse disc desiccation.
    Cervical cord demonstrates normal signal intensity. Cerebellar tonsils unremarkable.

    C2-3: There is broad based posterior disc bulge. There is mild to moderate bilateral neural formainal encroachment and at least mild central canal stenosis.

    C3-4: There is broad based posterior disc bulge with mild ventral thecal sac deformity. There is mild to moderate bilateral neural foraminal encroachment and at least mild central canal stenosis.

    C4-5: There is broad based posterior disc bulge with mild ventral thecal sac deformity. There is mild to moderate bilateral neural foraminal encroachment and at least mild central canal stenosis.

    C5-6: Posterior paracentral disc protrusion with ventral thecal sac deformity. This does not abut the cord. There is mild to moderate bilateral neural foraminal encroachment and at least mild to moderate central canal stenosis.

    C6-7: Endplate spur visualization, mild ventrical thecal sac deformity and mild bilateral neural foraminal encroachment with mild central canal stenosis.

    C7-T1: No disc protrusion, neural formainal encroachment or central spinal stenosis.

    Impression:
    At least mild to moderate central canal stenosis due to posterior paracentral disc protrusion identified at C5-6 that does not abut the cord.

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