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Hello Dr. Corenman,

Thank you for your website, educational resources, and answering individual questions. I read your noted articles back in December and have re-read them multiple times. My journey still continues. Recap is that I had ACDF C4 to C7 in Sept 2018. I was pain free for about 7 months, and the left radiculopathy/weakness returned at 11 months post-op. I had CT myelogram at 1 year post op that suggested I was spot-welded at C6-7 with “possible small area of partial fusion anteriorly and towards the right, but without solid fusion elsewhere across disc space.” It also said “At C6-7, there is mild spinal canal stenosis and mild bilateral foraminal bony encroachment.” My tricep weakness and pain seem to correlate to a C7 nerve root issue. You suggested I get an SNRB at the left C7 nerve root. I am still working on trying to get that.

I did get EMG back in October that showed “mild chronic and inactive left C7 radiculopathy” along with “mild left ulnar neuropathy at the elbow”. I was told do nerve gliding exercises and wear a brace for 4 to 6 weeks. When that did not work, I tried steroid diagnostic/therapeutic injections first at the elbow (which did not help) and then at the wrist (which helped). I ended up having left ulnar nerve surgery some 3 weeks ago (decompression at cubital tunnel and Guyon canal) as well as carpal tunnel release. It has helped with the finger numbness, but I do not know effect on strength yet. Even though EMG showed the issue to be mild, hand surgeon said the elbow compression was severe and far from what he expected to see. There was quite a bit of tissue inflammation, nerve inflammation, and it was so attached to scar tissue that he had to go further up the arm than normal, along with encountering a pocket of blood. He asked if I had been in an accident to explain the condition, which I have not. I am hopeful that I will see a big change with this surgery. But, this does nothing for the pain and weakness above my elbow.

Unfortunately 6 weeks ago, I fell onto the top of my head. The force axially loaded my spine, though it might have loaded a little more in flexion than a straight axial load. The pain down my spine was like a lightening bolt, down to the base and back. Then, there was intense heat/burning at my ear lobes with a tremendous occipital migraine. The ER did a cervical CT which included a short radiological report that said “Hardware intact and no significant osseous abnormalities noted”. There was no level by level assessment. Spine surgeon looked at the CT images and said that I am now fused at C6/7 and that discs above and below were fine. He said my fall was insignificant and pain was likely muscular. He suggested trying a chiropractor and trying PT again, even though I did PT for my radiculopathy from Sept to Dec without meeting any of my PT goals (no decrease in pain or improvement in strength).

From the fall, I now have new pain, from near daily mild occipital headaches, constant burning in my neck, constant hatchet in my back, constant ice pick in my low back, transient left and right flank pain, and transient left sciatica. I also have left foot drop, left leg weakness, and restricted ROM on left side along with my previous complaints of upper left extremity and now some upper right extremity pain.

Chiropractor ordered a cervical MRI, then later a thoracic and lumbar MRIs because cervical MRI showed possible marrow edema at T3 that needed to be further investigated. I have been previously identified as having a congenitally narrow cervical spinal canal (previous CT myelogram in September said “thecal sac measures at most 8 to 9 mm at C2 and C3, at most 1 cm at C4 and C5, and at most 9 mm at C6 and C7”). With that in mind, highlights of the recent cervical MRI are:

C2-3: Posterior element hypertrophy with left foraminal encroachment; annular bulge measuring 2 mm, posterior spinal cord abutment and slight indentation complicated by flaval ligament thickening. Clinical correlation for left C3 radicular involvement and myelopathy recommended.

C3-4: Disc height narrowing and dorsal bulging measuring approximately 2mm posteriorly. There is mild right and moderate-marked left posterior element hypertrophy. Retrolisthesis of C3 measuring 1-2mm noted. Encroachment of both the ventral and dorsal margins of the spinal cord with slight indentation posteriorly complicated by flaval ligament thickening. Clinical correlation for associated radicular involvement and myelopathy recommended.

C4-C7: Evidence of prior anterior cervical discectomy and fusion. Posterior elements are normal. No specific findings of central or neural foraminal stenosis or spinal cord or exiting nerve root compression.

C7-T1: Disc narrowing and derangement with posterocentral 2-3mm focal herniation encroaching but not overtly compressing the ventral spinal cord margin. There is right-sided facet joint hypertrophy and encroachment of the corresponding neural foramen nerve root. Clinical correlation for right C8 radicular involvement recommended.

I also had a flex/ex xray this week that showed: “There has been interval osseous bridging of the C4-C6 vertebral bodies. Interval narrowing but persistent of the intervertebral space at C6-C7.” Does this mean that compared to the previous xray in November, there is a gap at C6-7 that has narrowed since November, but the gap still exists? What does that say about fusion at that level?

I hired a neuroradiologist to re-read the CT from the ER, since the ER report did not specifically look at each level. I gave this radiologist a copy of the report and images from the CT myelogram in Sept (that showed pseudoarthrosis) for comparison. Regarding the recent CT, he said “The disc space at C6-7 is unchanged in the interval, again with lucency in this region. The C6-7 level demonstrates artifact from prior CDF. There is very minimal ossesous spurring along the posterior margin of the disc space. Minimal encroachment of the ventral canal is evident. The foramina are remarkable for mild to moderate encroachment bilaterally, with uncovertebral spurring evident.” In the Impressions, he said “There is again lucency involving the disc space at C6-7 suggesting non-fusion. Again this is not significantly changed in the interval. Uncovertebral spurring at C6-7 bilaterally. This results in mild to moderate foraminal encroachment and can encroach exiting neural structures. The C7 nerve roots exit at this level.”

Also noteworthy, is that a flex/ex xray in August 2019 showed the spinous process difference of 1 mm each at C3-4 and C4-5, but 4 mm at C6-7. This stayed exactly the same for the flex/ex xray in November 2019 and in the most recent one of March 2020. My vitamin D levels have been fine but I was diagnosed with osteopenia this week.

As for the fall, I have some lumbar damage (but the discussion and questions do not belong in this thread) and compression fractures at T3 and T12 along with a herniated disc (also was told it was discogenic disc) at T11/12.

I have three questions:
1. Spine surgeon and neuroradiologist looked at same CT and came to different conclusions. Does one specialist generally have a better assessment of this than another? Spine surgeons work with spines on a daily basis and perhaps might have more practical experience in this instance. Is it more likely I am fused (based on assessment of surgeon) or not fused (based upon the neuroradiologist’s assessment, the 4 mm movement of the spinous processes on the flex/ex xray, and the “persistent intervertebral space at C6-C7” noted on the xray report)?
2. I had a steroid injection in my elbow and one in my wrist within the last 3 months. I have been advised to get steroid injections in neck (at C2/3, C3/4, and C7/T1), thoracic (T11/12), and multiple levels in lumbar, but that was before the diagnosis of osteopenia. Is this advisable with osteopenia (I am only 52)?
3. This is perhaps dependent on your answers in 1 and 2 above. If C6/7 is not fully fused but has made some progress in fusion, would steroid injections hinder more osseous bridging?

I am waiting for a 2nd opinion within my HMO, but the next available appointment is more than 3 months out. However, I will see a physiatrist soon to talk about SNRB or ESI’s. I am inclined to get the SNRB on left C7 so that I have more information as to whether or not this is the culprit of my ongoing left radiculopathy and weakness. But then, I still need to address the pain and damage from my fall, as it is not getting better.

Many thanks!

I had hemilaminectomies with diskectomy surgery. Since I had posterior scar tissue, I was advised to have an indirect decompression via XLIF.

Below are the MRI results, with comparative MRI obtained in between diskectomy and XLIF surgery. The MRI was performed approx. 8 months post XLIF

FULL RESULT: EXAM: MRI LUMBAR SPINE WITHOUT AND WITH CONTRAST CLINICAL INDICATION: spinal stenosis, lumbar region
TECHNIQUE: A variety of MR imaging pulse sequences were performed in the sagittal and axial planes before and after gadolinium administration for evaluation of the lumbar spine. COMPARISON: 6/22/2018.

FINDINGS: There is a dextroconvex scoliotic curvature of the spine.

Since previous examination there is been interval placement of hardware at L3-L4 and L4-L5 with intervertebral disk spacers.
There is persistent hardware and an intervertebral disk spacer at L5-S1.
There is a 3 mm retrolisthesis of L2 on L3 and a 3 mm anterolisthesis of L4 on L5. There is an 8mm anterolisthesis of L5 on S1. The vertebral body statures above the level of the hardware are maintained with normal marrow signal intensity. The disk heights are preserved. The conus terminates at L1-L2.
Sagittal images only through the disk space of T10-T11 through L1-L2 demonstrate no significant disk bulge or disk herniation.
At L2-L3, the disk space appears normal.
At L3-L4, there is mild to moderate bulging of the disk eccentric to the right and posterior endplate ridging. There is bilateral facet
degeneration and infolding of the ligamentum flavum. There is moderate
right and severe left neural foraminal narrowing. There is mild to moderate spinal stenosis eccentric to the right abutting the traversing nerve roots.
At L4-L5, the patient is status post left hemilaminotomy. There is mild bulging of the disk and posterior endplate ridging. There is bilateral facet degeneration and infolding of the ligamentum flavum. There is moderate bilateral neural foraminal narrowing. There is mild spinal stenosis. There is enhancing scar tissue adjacent to the thecal sac eccentric to the left of midline and surrounding the exiting left L5 nerve root.
At L5-S1, aside from the anterolisthesis, there is minimal bulging of the disk and posterior endplate ridging. There is bilateral facet degeneration. Patient is status post laminectomy. There is mild to moderate bilateral neural foraminal narrowing. The central canal is patent. There is enhancing scar tissue to the right of the thecal sac.

IMPRESSION: Multilevel spondylotic disk disease status post fixation of L3-S1 without significant interval change in appearance since previous exam noting multilevel neural foraminal narrowing and spinal stenosis as detailed above. Persistent postsurgical changes at the L4-L5 and L5-S1 levels.

Well good news is that the flank pain is mostly gone now. I also had an MRI of my Cervical area recently that showed no issues.

It is just the bilateral leg pain/ that travels to the toes.

My main symptoms are

Constant pain in legs
Pain or weakness when standing of sitting for too long
Intense episodes of Heating/ Sweating
Burning Feet
Headaches
Lacerating or stabbing pain in legs

Also

Cannot do straight leg raise
Weakness in legs
Hyporeflexia in Legs
Abnormal gait

I don’t meet with my Surgeon until April. I’m worried because perhaps this might be Epidural Fibrosis or Arachnoiditis. Wouldn’t the MRI ruled out these possibilities or can these still be origin of my problem?

Im schedule for an Epidural Steriod Injection Thursday, would that be advisable?

The original lumbar spine MRI was a result of severe hip, and calf pain that happened after carrying a large suitcase down a flight of stairs. It started with a cramp in my hip and started traveled into the side of my calf a few days later. After a week it became difficult to sit for any period of time. I did not have any back pain. I would get a shock like jolt when I would stand up or turn at the waist. I developed weakness in the right leg along with drop foot and it became more difficult to walk. I thought I was having a problem with my hip and had no idea it was my back causing the problems. The pain level was about an 8. I went to the chiropractor to get an adjustment. I explained my symptoms to the chiropractor and he tried to adjust me. As soon as he positioned me a had the electric shock pain shooting down the right side. I decided it was time to visit the orthopedic for further evaluation. The Dr. immediately recognized the symptoms and referred me for a MRI and neurologist follow up. 2 weeks later none of the symptoms changed and I went to my neurologist appointment and was immediately scheduled for surgery. I had nerve compression at L3/L4 that was causing the problems. After surgery I had instant relief of the pain and symptoms. that was August 2018.

December 2018 my back felt better that it had in years. I was on a forklift at work moving some pallets and had stopped to let another forklift pull out of an aisle when I was struck from behind by another forklift. I immediately felt pain from my neck down to my tailbone. I was taken to the hospital for evaluation and a CT scan. The CT scan did not show any major trauma. For the next several weeks I was in a considerable amount of cervical and lumbar pain 8-10 when walking around and a 5-6 at rest. I started to lose sensation in my hands and had numbness in my fingers and thumb. The pain in the neck was dull aching pain with some shock pain when turning my head. I made an appointment with my surgeon for evaluation. I had some hyper-reflexia and tested positive for Hoffman’s sign. I had the 2nd MRI and the surgeon said there was nothing that needed immediate surgical repair. I was referred to PT and chiropractic care. I did the 8 weeks of PT and several months of Chiro care. The pain and numbness slowly got better but i never recovered completely (symptoms never fully went away). I still have numbness in my hands and electric shocks that run down my arms when I turn my head left or right. I am also having stiff neck and mid back spasms daily. The pain is in the base of my neck down to the middle of my shoulders pain is 5-7. The pain is mainly dull and achy with some sharp pains. Over the past 3 months the intensity has increased and the duration has also increased. It has been about 4 months of neck/upper back ache pain level 5-8. Pain in my left and right shoulder that goes down the triceps and the lateral forearm. Pain ranges from a 5-8 depending on activity. Also have loss of sensation in thumb and index finger left and right hand. They constantly feel numb. Lying on my back makes it feel a little more comfortable pain around 2-3. Dull ache between my shoulder blades 2-3 resting and 6-8 sitting at a desk or driving. It started to become difficult to sit at my desk and driving makes me uncomfortable. I hope this is helpful for your evaulation

Thank you for your reply. To answer you to the best of my ability.. hopefully the information below will assist in answering my original question.

1) L4/5 has retrolisthesis of 3mm on X-rays.

2) My spine curves to the left at L3-5 looking at front view of X-ray, unsure where rotation begins but rotation extends to ribcage as it is obvious, as well as my left hip and shoulder are higher. I was 5ft (before disc height loss) and weight fluctuates from 100-105lbs, so easy to see. I had no idea of the fact that I was born with SBO, with transitional vertabrae and Chiari 1 malformation until I started having pain in early 30s. I knew of scoliosis only. I do know all is not uncommon, and do not think it caused my issues in silo, but tend to think abnormal spine alignment is like a car, the longer driven out of alignment, the more issues that result. Especially since I was involved in high impact sports from early childhood until onset of LBP in 30s.

I looked on my operative report from 2011, and at that time it was noted that the interspinus ligament at L4/5 eroded away, and L5/S1 interspinous ligament was removed. Not sure if that has any significance in L4/5 pathology. I was fused without correction of the spondylolisthesis, which report indicates is 8mm.
Also see noted in recent surgeon’s notes “there is significant loss of disc height at L3/4 & 4/5. Nothing exact, but looking at side view of spine, L4/5 looks ~1/2 the height of my L2/3, L3/4 slightly higher, but not by a lot.

3)As with last episode that almost resulted in fusion, I started with more notable increase in general LBP and difficulty standing/walking, then left radicular pain along same nerve distribution to include left hip, lateral leg and tibia pain. Then severe right side back pain that I questioned being a kidney infection because never had pain radiate to the right, and it became relentless.

Then about 2 weeks after the back pain was incapacitating, given being stuck on the floor, suppose muscle spasms in back, started sudden onset of vice like muscle spasms in gluteal and quad muscles, left groin pain, saddle numbness and knee buckling with foot drop. It hit me like a ton of bricks, seemingly out of nowhere when I thought it could not get worse. I realize based upon imaging, that the disc material took its time to impact nerve root it is under.

I have tolerated back pain that lead to modifying my life, unable to travel, drive long or walk my dog, to avoid surgery. It was suggested 15 months ago that I have an extension fusion – but now am getting conflicting opinions. Clearly I would not be asking if I could resolve the conflict in my brain now.

Given I am 46yo, my concern is
1) I think the likelihood, based on my history and comorbid diagnoses of PSA, Sjogren’s and familial pattern hyperextensive joints, is that I will need to address back again regardless of which surgery I decide on.

A) Will not addressing all compressive pathology that would require fusion due to preexisting retrolisthesus and 2 level involvement lead to further interventions at L3-5, that statistically will likely not respond, and have posterior scar tissue issues? Then my life has sucked due to back for 15 months, and although no guarantees, I would like the opportunity to have less of the feeling like something is squeezing/ pressing on my spine, not go to status quo that I accepted to avoid surgery.

B) Which is the a bigger concern?
1) Risk of more surgeries at the same levels and possible permanency of nerve issues or
2) Risk of new ASD which will may result and may happen regardless of what I do?

At 46 yo one thought is I am likely to be healthier now, to endure a bigger procedure. Then the opposing view is fusing will most likely result in another surgery for ASD at a later date.

So in my brain I am kicking one or the other ‘can’ down the road. Which one is more reasonable to kick?