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in reply to: When do you decide a non union is pseudoarthrosis? #32541
Hello Dr. Corenman,
I tried to edit my earlier response to add in the last paragraph that the CT done in January (16-months post- op) showed “Minimal encroachment of the ventral canal is evident. Uncovertebral spurring at C6/7 bilaterally. This results in mild to moderate foraminal encroachment and can encroach existing neural structures.”
in reply to: When do you decide a non union is pseudoarthrosis? #32540Hello Dr. Corenman,
I was finally able to get a 2nd opinion within my HMO. Though not the ideal situation, my consult was a telemedicine appointment (so no physical exam). The new surgeon ordered a SNRB on C7 (Yay and thank you for recommending it back in the Fall!). I had that two weeks ago. The pre-procedure pain was a 5. With the Spurling Maneuver, it went up to a 7 before the procedure. Afterwards, pain was a 2 and Spurling maneuver did not increase my pain. I forgot how nice it was to have little pain. Unfortunately, the pain started coming back at about 2.5 to 3 hours post-procedure and was totally back around 4 hours post-procedure. I was hoping that the steroid would help, but they have not made a difference.
After my fall at the end of January, I started having low back problems (pain and left leg weakness). At L3/L4 level, the thecal space is less than 6 mm (apparently there is a herniated disc compressing from front, a bone spur, thickened flaval ligament and a gas-filled synovial cyst). I just had a nerve study and it shows that I have L4 compression, which explains the left leg weakness.
Unfortunately, I have to wait until late July to have a face-to-face appointment with new surgeon. He mentioned surgery in my telemed visit. He said low back was an easy surgical fix and felt that waiting until August for surgery would not have a detrimental effect on nerve recovery. He also said that neck was more complicated and we needed to have a pro/con discussion. Furthermore, he agreed with neuroradiologist and said that January CT showed a little more fusion at C6/7 but I was not fully fused and there was still movement across spinous processes (> 4mm). Finally, this surgeon said that since my symptoms have been going on since August, my tricep and hand weaknesses might not fully recover and I might have permanent nerve damage from waiting.
My question for you is this:
It is now 20 months post-op from ACDF. There is a small bone spur that was seen on the left C7 level in the left oblique image of the CT myelogram done at 11-months post op, but CT report denotes it as only “mild bony foramenal encroachment”. CT at 16-months post-op showed a little more fusion than CT at 12-months post op, but still mostly not fused. 18-months post-op flex/extension xray showed same amount of movement at spinous process at C6/7 as flex/extension xray taken at 11-months post op. EMG in October showed “chronic inactive C7 Radiculopathy”. SNRB test indicated that left C7 was pain generator. Pain was a 0 and there was no noticeable weakness from 6-months post op to 11-months post op. Given that info, would you recommend more testing (and if so, what)? Would you recommend waiting it out until the 2-year mark to see if I might achieve full fusion? Or would you recommend surgery (and if so, what surgery)?in reply to: When do you decide a non union is pseudoarthrosis? #32224Hello 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!
in reply to: When do you decide a non union is pseudoarthrosis? #31708I had the EMG/NCV study that revealed two things: 1) mild left ulnar neuropathy at elbow (cubital tunnel syndrome), and 2) mild chronic and inactive left C7 radiculopathy. It was explained to me that the C7 damage was prior permanent damage that could have occurred prior to my ACDF surgery 18 months ago (and thus not the current pain generator and not connected to the hand weakness). This did not make much sense to me because I had no issues after surgery until 11 months post-op. It seemed like it had to be a “new” issue that started with my symptoms in August. I was told to wear an elbow brace at night and while working at the computer for 6 to 8 weeks, and that should make me significantly better. I sought out another different Sensory NCS Type III (A-delta) test (only sensory based, no EMG portion to it) which showed moderate sensory issues with the Left C7 nerve root. This was done by a chiropractor who said that the sensory changes were seen at the nerve root exit. He was confident that the left C7 nerve root was the pain and problem generator.
Over the course of wearing the brace, my arm pain and weakness increased more. I also started having elbow pain and stiffness (which I did not have previously). Spine surgeon said I could have a case of double compression and said he wanted me to get elbow resolved before considering anything further with neck. He did say that perhaps there could be some positional compression that just wasn’t seen on the CT myelogram when I was laying in a neutral position.
I saw hand surgeon. He decided to do diagnostic and therapeutic block at the elbow. He said that I would know fairly soon if cubital tunnel surgery would tend to be effective, based upon my response from the injection. Other than some injection site pain and bruising, I did not notice anything. I might have had a slight change in sensation of my skin, but it was not even what I would call “tingling.” It certainly was not pins and needles numb, which it gets when resting on the table or when I wake up at night. I cannot rule out that maybe the change in sensation was in my head. I have not notice an improvement in the weakness, though it has only been a week since that injection.
I see the hand surgeon again in a month to discuss the next step(s) and the spinal surgeon visit is in 2 months. In September after the CT myelogram, I was told that the pseudoarthrosis at C6/7 was not causing my pain, weakness, and numbness. There was some lucency at the tip of one of the screws in C7, but this was described to me as a bit of wallowing out, though the screw head was not yet backing out. The CT myelogram showed mild residual left foraminal stenosis at C6/7. At this point, would a SNRB injection add to the information that we already know? Is the pain likely from the mild stenosis that may become more irritated in sitting/standing positions? Or, can someone still say with confidence that my arm pain/weakness/numbness symptoms are NOT from the pseudoarthrosis? Perhaps my question really is: What is most likely causing my issues and will conservative treatments help (because I have not found any relief yet)? I feel like we are just kicking the can down the road.
in reply to: When do you decide a non union is pseudoarthrosis? #31310Hello Dr. Corenman,
Thank you for your previous responses and answers to all of my questions. I just wanted to give you an update. I recently went for a 2nd opinion, as my original surgeon told me to try PT, TENS, massages, and come back in 3 months. The new surgeon looked at CT w/myelogram and said that there was a bone spur that could be impinging the nerve root. He did concur with what you said that an SNRB could help determine if the spur was indeed the pain generator. He did not see an immediate reason for the weakness, which is progressively worse. Instead of doing the SNRB right now, he is sending me for nerve conduction and EMG testing. Also, he did confirm that looking at my flex/ex xray from August, there is > 4 mm difference across spinous processes at C6/7. Even so, he seems to think that there is still a good chance to achieve fusion at that level.
MY PT did a bit of an experiment. In supine position, she pulled my head in slight traction. That eased my arm/shoulder pain by about 2 notches on a 10 scale. Also in supine position, she gave me a 2# weight to lift with my left hand, extending my tricep. I could not lift it quite halfway up before my arm started repeat the experiment again. This time, I was able to get the 2 # weight all the way up, and my arm did not start quivering until about 3/4 of the way up. It was a definite improvement, but not a return to “normal level”. I do not think I could have raised a heavier weight, even with the traction.
I am beginning to notice more and more how the left arm and grip weakness are effecting my day to day living. It is annoying to ask for help in the simplistic of things like opening a jar or pushing down the back SUV seat.
in reply to: When do you decide a non union is pseudoarthrosis? #31173Thank you for your reply. I had allograft and the other two levels are fully fused.
As for levels above and below fusion per CT myelogram report, at C3/4 there is a “mild broad-based 1 mm central disc protrusion and early left-sided facet arthropathy; there is mild spinal canal stenosis mostly congenital in nature.” At the C7/T1 level, there is “a 1 mm disc bulge and mild spinal canal stenosis; there is mild right-sided facet arthropathy with mild right foraminal bony encroachment, and no left foraminal bony encroachment is seen.” Disc bulge and/or protrusion at C3/4 and C7/T1 were not noted in the CT and MRI reports that were done prior to ACDF surgery a year ago. Since the main adjective used is “mild” to describe findings in these levels above and below the fusion, I assumed these areas are not the pain generator(s)?
As for motion, the CT myelogram report says “no subluxation is seen.” However, a flexure/extension x-ray done about 2 weeks prior to the CT myelogram shows some mild motion: “Lateral alignment is normal in neutral position. 1 mm anterior subluxation of C3 on C4 in flexion with 2 mm posterior subluxation of C3 on C4 in extension. Sclerosis of the middle and lower cervical facet joints.” Or, are you talking about motion between the spinous processes at C6 and C7 when comparing flexion to extension?
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