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in reply to: Grafton bone protein – Cervical Laminectomy #34518
Good afternoon Dr. Corenman,
Thanks so much! I found a place only 20 minutes from my home that preforms peripheral nerve stimulation procedures, however the wait is approximately two months if your a candidate, after doctor reviews your paperwork.
In the meantime, I’ve been researching, reviewing my medical records, and looking over my notes. There’s two pieces of information that still get’s my attention, time after time, 1) MRI 5 years after 5 level laminectomy states “Hypertrophic changes are noted at each level deforming anterior margin of thecal sac” and 2) CT scan performed 6 years post laminectomy states ” C3-4: Bilateral uncovertebral spurring and bilateral facet arthropathy, mildly progressive since 5/19/2018. There is associated mild right and moderate to severe left foraminal narrowing”, “C4-5, C5-6, C6-7, C7-T1: Postsurgical changes. Spondylitic ridging and uncovertebral spurring at C4-5, C5-6 and C6-7, mildly progressive since 5/19/2018. There is associated foraminal narrowing, mild on the right at C4-5 and C5-6, mild on the left at C6-7”.
I am still dwelling on these because in my gut something just doesn’t seem right. My understanding is with a solid 360 fusion one should not have progressive “Spondylitic ridging and uncovertebral spurring”. I’m also perplexed on “C3-4 progressive bilateral facet arthropathy and Hypertrophic changes noted at each level deforming anterior margin of thecal sac”. My questions are:
1. Is there a possibility that there’s still some kind of micromotion going on from above information, multiple CT Scans show fusion?
2. Can facet arthropathy at C3-4 cause foraminal stenosis? I read online a case where a patient had severe trapezius spams with neck and arm pain that was caused by C-4 nerve compression. Can a facetectomies and or foraminotomies be performed to help with above?
3. Selective nerve root blocks were performed back in May with improvement. You mentioned that injection confirms that level is a pain generator, however it doesn’t tell you if nerve is permanently damaged. So I was thinking of getting another spine surgeon to take a look while I wait for peripheral nerve stimulation decision to be made. Is this a case you would be interested in reviewing?
in reply to: Grafton bone protein – Cervical Laminectomy #34502I did have ACDF’s. ACDF’s at C3,C4, C5, C6 and C7. In addition a partial corpectomy was performed at T1.
in reply to: Grafton bone protein – Cervical Laminectomy #34500Good afternoon Dr. Corenman,
I had selective nerve root blocks back in May and there were some pain relief at C3 and C5 and not at C7. Before my T2-T3 procedure, this was communicated to my surgeon and I asked if he needed something in writing from pain management and he said no and that he would open up nerve channels that are tight. To my surprise he told me after surgery nerve channels were not too bad, so he didn’t perform.
I’ve had consults with 2 different pain management doctors, who don’t work with each other, and a neurosurgeon and was told in their opinion, there’s residual compression. The neurosurgeon explained the bone spurs originate from the uncovertebral joint’s and should be approached from the front. He asked around in his office if anyone performs anterior foraminotomy and no one does. When I shared this with my orthopedic surgeon, he said there’s no way to fix this problem because bone spurs are imbedded with fusion. I believe you sent a message saying that the only way to correct this issue is with an osteotomy?
So at this point I’m stuck with pain and severe muscle spams and don’t know where to go. I spoke to pain management again and was told, my epidural space is deformed and to avoid any injections or SCS. Thanks as always for your continued support.in reply to: Grafton bone protein – Cervical Laminectomy #34488Good evening Dr. Corenman,
Thank you so much! The EOS scan shows solid fusion from C3-T1 and so does CT Scan. The surgeon stated that there is residual foraminal compression, however it’s not severe in his opinion, more like moderate. The neuroradiologist states in his report severe, surgeon say’s he looks at things from a different perspective. Also mentioned to me was at T2-T3 there was cervical spondylotic myelopathy and just because that level is now decompressed does not mean the nerves are fully recovered or will ever fully recover.
In reference to malalignment, he performed some measurements and said T1 slope and SVA is borderline acceptable. He gave me measurement of C2-C7 SVA at 39.9 mm and said over 40.0 mm normally requires surgical intervention. The imaging showed “straightening of cervical lordosis and thoracic kyphosis. Slight exaggeration of the lumbar lordosis with mild anterolisthesis at L5-S1 and minimal retrolisthesis at L3-L4. underlying mild multilevel discogenic degenerative changes. Mild bilateral hip osteoarthritis. Mild bilateral knee osteoarthritis”.
From your previous comment if one has moderate residual foraminal compression and some kind of malalignment (kyphosis) there is a high probability this is where my pain is coming from? Thanks
in reply to: Possible Residual Compression #34456Good evening Dr. Corenman,
I was reviewing my cervical laminectomy operative notes from 2013 and have a few questions please. It reads “OPERATION PERFORMED: Bilateral decompressive laminectomy from C3-C7 with bilateral posterior instrumentation and fusion using Medtronic’s instrumentation at C3, C4, C5, C6 and C7 with fusion from C3-7 bilaterally using allograft bone graft with Grafton bone protein bilaterally as well as autogenous bone bilaterally”.
My questions are:
1. Grafton bone protein is this off label for cervical spine? Thought FDA approved for lumbar spine?
2. Can Grafton bone protein cause neck pain, chronic radiculopathy, trapezoids spasm, etc.?
3. What can be done if this is an issue?
in reply to: Possible Residual Compression #34410Good evening Dr. Corenman,
The physiatrist’s does not work together. I’m attaching the CT Scan report below:
***CT Scan****
FINDINGS:
Postsurgical Changes: Postsurgical fusion changes, appears to reflect a revision/addition since 5/19/2018, now appears to involve C3-T1 with multilevel postoperative hardware and decompressive laminectomies. Hardware appears intact, appropriately positioned without evidence of failure or loosening. Bony fusion appears solid at C3-4 through C7-T1.
Alignment: Lordotic straightening.
Vertebrae: Normal in height.
Soft Tissues: Expected postoperative changes.
Disc Spaces:
C2-3: Tiny central disc herniation. There is associated minimal mass effect on the anterior thecal sac without significant central canal stenosis No significant change.
C3-4: No significant disc disease. Bilateral uncovertebral spurring and bilateral facet arthropathy, mildly progressive since 5/19/2018. There is associated mild right and moderate to severe left foraminal narrowing.
C4-5, C5-6, C6-7, C7-T1: Postsurgical changes. No significant disc disease. Spondylitic ridging and uncovertebral spurring at C4-5, C5-6 and C6-7, mildly progressive since 5/19/2018. There is associated foraminal narrowing, mild on the right at C4-5 and C5-6, mild on the left at C6-7. No significant foraminal narrowing at C7-T1. No significant central canal stenosis at any of these levels.
Spinal Canal Contents: Limited by CT technique, grossly unremarkable
You note “At C3-4 (the level above the fusion), there is “mild right and moderate to severe left foraminal narrowing” which could cause left-sided neck, anterior chest wall and shoulder pain”. I have anterior chest wall pain, with left more than right neck and shoulder pain.
The EMG also states ” Needle evaluation of the left biceps and the left triceps muscles showed diminished recruitment. The left mid cervical paraspinal muscle showed moderately increased spontaneous activity. Left Biceps Musculocut Nerve C5-6 “Reduced” and Left Triceps Radial C6-7-8 “Reduced”
I have the following questions please Doctor:
1. Does the information above show perhaps a posterior foraminotomy at left C3-C4 can alleviate the anterior chest wall, shoulder and neck pain?
2. Can foraminal stenosis on left side C3-C4 cause pain and spasms additionally on right also?
3. “Paraspinal muscle showed moderately increased spontaneous activity” is this due to surgical muscle trauma or nerve root stenosis?
4. I sill have base of neck pain bilaterally still waiting for T2-T3 to fuse. EMG states “electrodiagnostic testing reveals evidence of left C5-6 cervical radiculopathy without distal denervation”. It sounds from your previous correspondence, that maybe chronic radiculopathy persists at this level since “Mild narrowing does not typically cause nerve root symptoms”
5. Should nerve blocks be in store for C3-C4 and C5-C6?
6. My last question is currently in physical therapy for the past 4 weeks. The Doctor of physical therapy tells me during my massages that my traps gets tighter and tighter with motion to the point where they feel rock solid. They place me on my back and hold my neck with their hands with very little load of my neck weight on my spine and turn my neck gently to the left and right like a windshield wiper. They can’t seem to understand why motion is making matters worst. I’ve done some research and it appears that this can signal pseudarthrosis and I’m really confused since the radiologist notes “Bony fusion appears solid at C3-4 through C7-T1”, however he goes on to say “Spondylitic ridging and uncovertebral spurring at C4-5, C5-6 and C6-7, mildly progressive since 5/19/2018” sounds like there’s some kind of continued motion still going? So maybe the focus should be on posterior foraminotomy at C3-C4 left and perhaps revision ACDF’s at C4-5, C5-6 and C6-7? Do you have an information you can share on this? What is the protocol? Is this a case where a surgeon would have to use his/ her judgement and go in to inspect fusion status? If there’s a solid fusion, how about an anemic fusion, where there’s still some kind of motion going on? How can this construct be reinforced?
Thanks again for all your help! This pain is driving me nuts, I’m beyond fatigued, just doing my best to see if any information you provide will help in my journey to get this issue behind me. Thank you again for all your help, time, making this forum available for those who are struggling and not giving up, your feedback is giving us hope and may the lord, give you continued blessings and health, you deserve the best. Best regards Dr. Corenman
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