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Dear Doctor,
One of the questions I have asked is why would someone have an open-midline foraminotomy when they could have the minimally invasive method as you perform it, (other than not knowing better.) Basically you suggested it was just the way a particular surgeon performs the surgery and the result was the important thing. Peyton Manning has easy access to the best doctors and most advanced techniques in the world. Why he had the open-midline, muscle resecting method twice has confused me and continues to do so. My diagnosis is similar to his and the excellent surgeon I saw would use the midline-open procedure. (I do not yet know if he performs the minimally invasive as well) All things being equal I would of course prefer minimally invasive.

I have come across a case study by the doctor who performed the two foraminotomies on Manning on another major spine website. This patient has a C7-T1 herniation (like mine). The surgical choice was endoscopic foraminotomy/discectomy. So here is Mannings doctor performing the minimally invasive procedure on one patient and the open-midline on Manning). Clearly there is some surgical reason. Why? Why? Why?
Next another important surgeon comments on the case study and is praising Mannings doctor for performing the muscle sparing, smaller incision procedure. It seems Mannings doctor may have invented the procedure. Yet he does not use it for Manning…twice. WHY???

The surgeon I saw wrote he would do a foraminotomy and a laminotomy. He writes that there is probably no advantage to try to remove any part of the disc because it is likely quite hard (after 7 years……”I would rather decompress the nerve root posteriorly to an adequate degree to make adequate room for the nerves through the foramen” (He did tell me he would try to remove disc if possible.) He acknowledges the slight subluxation. “At C7-T1 there is a very slight degree of subluxation with C7 slightly forward on T1 and this is slightly more noticeable on his symptomatic left side. The patients C7-T1 level is relatively low set and his sternum is approximately 1 or 2 finger breaths below the C7-T1 disk space”

Why does Manning have the more invasive proceure???

Does the laminotopy open the foramen in a different place vs removing ½ the facet as you do???

Manning did have that herniation for years as I do. Is the open midline approach better for long standing (hardened) discs???

Is the open midline approach better where there is a (“very slight”)subluxation???

Would any of this change your approach or would you still do the procedure as you did on the C7-T1 posterior foramintomy video and remove the hardened disc.???

I do want to ask you to review my scans but I want to resolve every issue first and have decided the surgery is the right thing to do before burdening you with that. Also with degenerative changes at most every level and numerous, directly related injuries it is quite difficult. The injury timeline is important and takes a long time to relay. And I have an insurance issue delaying the SNRB.

Thank You as always

Dear Doctor,

How do you recommend the cervical selective nerve root blocks you speak of be performed? Are they from the side of the neck or by entering through C7-T1 and running a catheter up the canal?

Is there any difference in the C7-T1 level (where I need it now) or higher up such as C3-C4?

Thanks

Dear Doctor,
I’m back on my thread. I apologize for the length which I have avoided for quite some time. I have asked you questions about left side neck pain at c2-3 and c3-4(bulging disc with left lateral extension) and also c4-5 (bulging disc with left lateral extension, no or insignificant weakness) on other threads…(from a fall while jogging 8 years ago) but 6 months prior there was a left side weight lifting trauma in the incline bench press position. I felt a sharp pain and then and for years thought I broke my scapula. It is a certainty that it herniated c7-t1(left paracentral disc herniation causing mild impression on the ventral aspect of the thecal sac and moderate narrowing of the left side neural foramina. No central canal stenosis is seen. There is a 1mm-2mm anterior vertebral offset.) I did not have neck pain from this. This started later, a month or two after that jogging fall so about 8 months later. There is also a prior damaged shoulder.

I started with the doctors 3 years after all this. The herniation was missed back then by the radiologist and spine surgeon and a nerve test implicated the left cubital tunnel for ulnar neuropathy. I was uneducated back then and thought all the weird back, shoulder and arm sensations were shoulder trauma related. I had never noticed the significant atrophy to the interosseous muscles, most notably the missing first dorsal interosseous on the non dominant left hand. I saw an excellent hand surgeon who performed a “much needed” endoscopic cubital tunnel release. I had ignored immense pain from curls for years right at the cubital tunnel so it all made sense. At the time we knew nothing of the c7-t1 hernation and of course there was no benefit from the surgery.

By now I was educating myself intensely and replaying the history. Since this was trauma and not long time degeneration and since I still have a strong grip I came to suspect that maybe it was the T1 root that wasted the intrinsic muscles and coincidentally there is a bulging (not herniated) disc at T2. I do have pain around the c7-t1 and possibly t1-t2 spinous process, it is hard to tell. The hand feels week but is 100% functional .This nerve may have been double or even triple crushed. After this I met Dr Corenman and have read and reread everything and developed a staggering civilian spinal education. Every doctor remarks about it…”I have never had a patient who……. And yet I am unsure about a number of things.
I write this saga now because I just saw an excellent, conservative, 30 years experience spine surgeon/65% cervical surgery. (diagnosis-cervicalgia-primary….Displacement of cervical intervertebral disc without mylopathy…Cervical Radiculopathy) He dismissed the neck pain from c2-5 “we do not chase neck pain…we are good with arm pain, we are not good with neck pain”. He read the mri with me and I gave him an xray with flexion-extension I suspect he read prior. He refused all reports yet did pick up on the vertebral subluxation. He said it was left sided and did not seem bothered by it. He then offered a posterior foraminotomy at the c7-t1 level. He performs the open technique. He said he would try to do something (I forgot what) otherwise he would just remove the disc and decompress the nerve. He quoted an 85%-90% success rate. I intend to get a follow up appointment and find out this and more. It was a long enough appointment but we really did not get down into the weeds as this post does. I do not know if he realizes all the other potential pain generators or if it would matter to him since the mri and physical findings match. I intend to get a follow up appointment and find all this out.

My only issue is pain. Prior to the jogging fall and neck pain I do not think I would have surgery for the arm issues…not bothersome enough, and the hand muscles are long gone. But if this is causing the left inside scapula, across scapula pain, hand weirdness, pain near scapula and sharp pain at scapula, lateral forearm, wrist when moving head forward or back then the surgery might be beneficial. The indications and imaging seem obvious but I am concerned about how much pain is actually caused by this nerve ( I suspect a lot) but with c4 and c5 capable of the trapezius, scapula shoulder stuff, a subluxation, T1 and T2 suspicious and 8 years gone by well?????????? who knows. I know you would recommend an snrb and I would not have the surgery without it. For now, as I inch forward I have these questions for you.

1- I have read all the hoopla about minimally invasive and your comments on it. I understand all (spine) surgery carries risks. Still is a posterior foraminotomy a “minor procedure as it is portrayed to be…(“Peyton Manning underwent a “minor” procedure today”.) Do you consider/Is a posterior foraminotomy a “minor procerure???

2- Does the nerve being compressed concern you? If it is a pain generator can it still heal? Can their still be any hand strength improvement???

3- Does a 1mm-2mm anterior vertebral (subluxation) concern you for a posterior foraminotomy???

4- The doctor spread his fingers about 2 inches and the scar would be down the midline….as Manning has. Precisely where is the scar that you show in your c7-t1 posterior foraminotomy video with the ruler of less than an inch. It seems I may need this identical surgery. Is it midline, off to the side…where???

5- Major doctors like Peyton Mannings doctor and this doctor perform this procedure open. You perform it with the small incision and microscope which obviously seems preferable. I have trouble believing they cannot do minimally invasive. Do they see more or something else…are there different indications or is their no real difference.???

6- If there were two greatest doctors in the world. One did the procedure open and one through the small incision (you). One was in your area, the other involved air travel. Where would you take your family to have a posterior foraminotomy performed. Do you think it is significant enough to travel for the small incision and microscopic method vs the open method???

Many many thanks