I am a 45 year old very active male. I train intensive Karate (Shotokan) 6 times a week. About 8 months ago I experienced (RHS) medial scapular pain and pain radiating down the top of my arm with pins and needles in my forefinger, index finger mainly (No neck pain though). This started off intermittently and progressed over the next 5 months to becoming more or less constant (much worse when I sit) Pain level is about 5/10 practically, however at the end of the day, because it is incessant, feels like a 9/10. I thought that I had just torn a muscle and continued to train through the pain. Eventually in April, I saw a Neurosurgeon who sent me for an MRI and EMG. He said that I have moderate to severe spinal stenosis at 4 levels C3/C4-C6/C7. In addition I have bilateral foraminal stenosis at all of these levels with severe stenosis on the RHS at C4/C5 and C6/C7. I also have herniated discs at all these levels the worst of which is at C6/C7. I have no cord signal change yet. To date I have seen 3 Neurosugeons. One of them said that I need to have 4 level ACDF. THe Next said that he would definitely not do a 4 level ACDF as in his opinion it is far too drastic and would rather do a 4 level laminoplasty. The third Neuro (the one I have decided to go with) said that he would do a 4 level laminectomy (poissibly with fusion at 1 or more levels (in his words, much simpler than the laminoplasty and also that the laminoplasty would not give my cord sufficient space). In addition to the 4 level laminectomy, he says that he will possibly have to also to a single level ACDF for C6/C7 but would determine this while in surgery. My question is, does this sound reasonable? If I land up with a laminectomy with no fusion, is there not a good chance of developing an unstable neck and or Kyphosis? Should I not suggest to the Neuro that I have posterior fusion throughout 4 level? Also I worry about the fact that I will be left with a spinal cord that is exposed to further injury due to the fact that the protective lamina will not be there anymore. I continue to train however no body contact, only kata and some kihon (basic moves) all done as smoothly as possible. I have the surgery scheduled for the 29th July. Would really appreciated any feedback
Last edited by hilt; 07-08-2010 at 06:26 AM.
Reason: FOrgot something
An ACDF is much easier, for the patient, than a posterior cervical fusion. Taking everything into consideration you have to pick the option that best fits your needs and expectations. I had a C5-C7 ACDF and am now hoping to add C4. When I go into surgery I tell the surgeon "do anything you feel necessary, if the ACDF has to be extended or solidified from the back of the neck please feel free to do so". You don't want to be in a position where every few years you need more surgery (unless things change over the years).
I agree with you that stability is very important. So you want to avoid anything that leaves remaining levels of instability. I probably say this too much but this is why I am a fan of the ACDF. When done for the right levels it gives a permanent level of stability and with disc material removed it helps minimize or eliminate nerve or cord impingement.
If you are concerned about the exposure of the cord to damage, then why not reconsider the laminoplasty? That doubles the room in the canal and gives you the protection of the cord at the same time. They don't need to remove the disks due to the extra room given and the foramen can also be opened to allow the nerves freedom to exit without being compressed. It is a new surgery and far more complex than just going in and breaking some bones off your vetebrae and getting out again. It involves re-building the back of the vertebrae and is really cool but takes know how. If you'd like more info on it, I'd be glad to tell you more. But it takes time and skill to do it and I think your surgeon just doesn't know how to do it .
Very few neurosurgeons do laminoplasties and the other NS's might not be able to do it or very familiar with it. I had a 4 level laminoplasty in 2006(C3 to C6). My own experience is that the ones who don't know how to do it will put it down rather than tell you they don't know how to do it. It also means no fusion and full movement of your neck. I was back to work after 2 1/2 weeks.
I will freely admit that I have had other problems since but it had NOTHING to do with having the laminoplasty. I simply dislocated 5 vertebrae and broke 3....it a long story. And now as a result of the fractures, have developed severe arthritis and face more surgery to remove bone spurs that are pressing on my spinal cord.
But the laminoplasty was neat. I woke up with all pain and numbness gone. The hardest part was re-gaining the strength in my neck muscles as it's done from the back.
The more they fuse, the more trouble you will have. I am now a 6 vertebrae fusion(posterior C3 to T1) and that may soon expand as the massiveness of the fusion is destroying the vertebrae below it as well as the arthritis.
If you want to keep doing your karate, don't go for a fusion of any kind. And I'd also say don't do the laminectomy because 1 hit to the back of your neck could be disasterous. You need to get some straight answers from your docs about your future before you make any decisions. I think you've been fed some mis-information regarding what is best to do IF you want to keep up with your career.
If I were you, I'd do the laminoplasty. Once you fuse you can't go back. At least with the laminoplasty, you can always have a fusion done if it doesn't give you enough pain relief. And my neck was worse than yours....cord compressed at multiple levels down to half thickness at the worst. If it worked for me it can work for you.
HI Jenny thanks for that. I live in Melbourne and the issue with Laminoplasty I think, is that I dont believe that there are many, if any surgeons that do a lot of this procedure here. So while I agree with you that Laminoplasty seems to be a good option, I dont want to force a surgeon to do this if he is not comfortable to do so. I was in LA last week and saw a very good Neurosurgeon - suggested Laminoplasty (and does this procedure regularly) however I have to have this done in AUstralia. In terms of training, I do not do any body contact stuff anymore, only stuff that consists of basic and complex exercises done smoothly. But thanks for your points I really appreciate it.
THanks so much for replying. It has been so difficult to decide what to do. In Australia the golden standard seems to be ACDF. The reason that I am going for a posterior approach is that the surgeon that has suggested this is regarded as the best in Melbourne. I just worry about the lack of protection due to the mising lamina.
My 6 level fusion is from the back. There are newer methods that allow more flexibility and therefore more strength in the fusion. I have 2 rods that run the length of my fusion and even if I have to now go to laminectomies due to massive arthritis, the rods will at least give me some protection.
What I would say is go for the least number of fusions as you can. You can always extend them but once done, you can't go back and the bigger the fusion, the bigger the problems after wards. So your 3rd doc does sound the best. They can do a single level from the back or front(ACDF) or something they call a 360* fusion where they do it both front and back.
You are always going to have to be careful even with the lamies in the back. I'm waiting to hear from my surgeon next week on what he's going to do for me as it looks like my only recourse is laminectomies so I'll try to find out if anything else can be done. I liked knowing my cord was protected but I have massive osteophytes growing from the area of the laminoplasty grafts. Filled the canal and are growing into the cord.
I wish there was some way to protect the cord and I'm going to be asking a lot of questions when he gets back(speaking at an overseas conference)and If I find out anything, I'll let you know!
Its amazing how much knowledge one picks up when you are in the firing line. Yes I believe that 360 (or circumferential surgery) is what I am going to have. I also have osteophytes by the way. Surely if you are fused at 6 levels the pain issue should be resolved? What is your range of motion like after the fusion. Can you notice a marked difference. I have scoured the net and cannot find any conclusive text that explains how much range one looses per level fused. I have my surgery scheduled for the 29th July and I must say even though I know that I do not have a choice, it is a very frightening prospect. Good luck with your surgeon thogh . I would be interested to hear what he has told you. Thanks again for your input.
All the best Hilt
If it helps, I'm fused C5-C6-C7 and have minimal loss of range of motion. If I add C4 I expect to loose a bit more. I bought a panoramic rear view mirror for my car which was a great purchase. I can strain less when needing to back up, etc.
My situation is different in that I appear to have both system wide ligament and tendon laxity (entire body) as well as ongoing permanent spine degeneration. So I'm not 100% pain free. BUT, waking up from ACDF I felt 100% better. I have some pain issues but the ACDF relieved so much of the nerve pain it was incredible! I wanted to go home that day I felt so good but my surgeon insisted on 2 night in the hospital and wearing an Aspen cervical collar for 6 weeks. I hate stuff around my neck and had a bigger fear of the collar than the surgery. But I am very glad I had the collar. It helped me maintain good positioning and gave me reassurance. I even managed to sleep in it.
Before the ACDF I had significant nerve pain. In my case it was a 4earing nerve pain that traveled down my left arm and into my fingers. I had some numbness and tingling in my hand and fingers. At times it was a level 9 out of 10 and it could last for quite a while. There were times when the pain was less noticeable and more manageable. I was using vicodin and flexeril along with anti-inflamatory meds such as aspirin, naproxen, and ibuprofen.
The most stunning thing was waking up in the recovery room immediately after the ACDF and the searing nerve pain was gone. I waited a bit too long to have the surgery so I have some numbness in the tip of one finger that is permanent. Nerves take a long time to heal so there was no way of knowing if that would remain, but it did.
Hi Karin. Thats so great that you have gotten rid of your pain to a large extent. My pain is much worse when I sit (very strange). Itstarts in my back under my scapula on the RHS and then sort of radiates up over my deltoid and down the top of my arm to my hand. I have pins and needles at times in my forfinger and middle finger. I would say that the pain is about 5/10 however at the end of the day feels like a 9/10 as it has been relentless the entire day. I grade it as a 5/10, if I compare it to the pain that I have felt, say burning my hand on a hot iron which would be a 10/10. THey reckon that there is only a 75% chance that I get rid of the pain after the surgery. I have tried to stay off the hectic meds , and I am taking a cocktail of anti-inflamatories, paracetamol and nexium (for my stomach and the anti-inflamatories). THe problem is that I have a business to run and I need to have a clear head all the time. I hope that I am not left with any numbness as I have been playing the classical guitar for 30 years and definitely cannot afford to loose any feeling or dexterity in my hands. Anyway I guess what will be will be!
I just wanted to follow up for anyone who wanted to know. I had the surgery on July 29th and it is now 12 weeks after. I landed up having the 4 level Lami C3-C7 .The surgery was rough. I spent 6 days in hospital in a lot of pain. Very Stiff Neck and lots of spasm and pain in my upper back muscles. I got up and walke the next day around the ward albeit in a lot of pain and discomfort. I then stayed home (mostly lying down ) for the next 2 weeks and then went back to work full time. I still have pain in my arm although not as severe as before the surgery. My Neuro says that I need to wait another 12 months or so to see if it settles. If not I may have to have an ACDF which he assures me will get rid of the pain. I have done exercise from the beginning , walking about 5 kms per day after week 2. I now am back to stationery cycling, walking and karate, however I have to moderate my movements and try to keep my head as neutral as possible. I also do at least 45 mins of core and neck strengthening exercise each evening. I would say that I am only now really strarting to feel sort ouf normal again.