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Old 12-29-2011, 08:06 AM   #1
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One Year post ACDF and problems

I am one year post a C4-C7 (I forget if that's a level 3 or 4) ACDF. (surgery date 1/19/11)

I've been having pain issues ever since surgery. I initially attributed this to healing. My pain symptoms have gotten a little worse, both in severity, and area affected. I'm having neck, shoulder, arm and hand pain, right hand especially, in all my fingers, the back of my hand, wrist, forearm, bicep, tricep, deltoid, pec, etc.

My original issues were from herniated discs, central canal stenosis, neural foraminal stenosis and degenerative arthritis.

I had an MRI done on 12/24/11. I confess that I don't quite understand what this mri is saying. What it appears to me is, the central canal stenosis has not been fixed. How can this be? I guess I assumed when they did surgery and removed my discs and replaced them with cadaver bone, that they would also remove the pressure from my spinal cord. I also thought that they would fix (if this is even possible?) the neural forminal stenosis I had. I've attached results from my latest mri. Anyone want to take a guess? I have a doctor appointment, but it's not until after the new year, and the waiting is killing me!

I feel like I went through hell, for nothing. I'm confused. Maybe my mri isn't that bad, but it sure seems like it.
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File Type: gif mri2.gif (98.0 KB, 11 views)
File Type: gif mri3.gif (48.9 KB, 5 views)

Last edited by Daner51; 12-29-2011 at 08:16 AM. Reason: adding second half of mri results

 
Old 12-29-2011, 11:05 AM   #2
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Re: One Year post ACDF and problems

To start with, you have developmental canal stenosis, which means that your spinal canal is too narrow TO START WITH. That's hereditary. It means that anything that intrudes into the canal over time can have an exaggerated effect because the spinal cord and the nerve roots have no leeway (and you have plenty of things intruding, I'm sorry to say).

C2-3 - This is a level that's usually non-problematic, even in people with severe problems farther down. That the radiologist only mentions uncovertebral joint hypertrophy - a bone alongside the vertebra expanding backward into the canal and into the openings (foramina) for the peripheral nerve roots - and that would not compress the thecal sac (the membrane filling the spinal canal) down to 8mm unless you started out with a very narrow canal. The thecal sac probably ought to be around 15mm at that level.

C3-4 - No problem with the disk but bone spurs on the uncovertebral joint and facets are impinging on the canal. Central canal stenosis is "moderate" (one step below "severe"). I don't think I've ever seen uncovertebral joints cause such a level of canal stenosis all by themselves, so that's further evidence that your canal is just way too small to start with. The impingement on the nerve root (foraminal stenosis) on the left side could certainly be causing neck/shoulder/arm pain and dysfunction.

C4-5 - This is the first level that should have been fixed. The "disk/osteophyte" complex occurs when the disk protrudes backward into the canal, and the vertebrae lay on osteophytes above and below it. I would want to know how you can have a disk/osteophyte complex WHEN THE DISK ISN'T THERE ANY MORE. Once again, the canal stenosis is only partly explained by the intrusions into the canal, and more explained (implicitly) by the developmental stenosis. The radiologist says the canal stenosis is "severe" (very bad) and that the cord is indented ventrally (from in front). Although this is the only level at which the cord is shown as indented, I doubt - just given the 6-7mm dimensions of the thecal sac - that this is only level at which the cord is affected. My guess is that it is flattened at other levels, which could be as bad as being indented.

C5-6 - this level appears to be fixed

C6-7 - "endplate osteophytes" refer to bone spurs growing off the back of the top and bottom of the vertebrae, where they used to come in contact with the since-removed disk. We don't know how bad "prominent" is, but it can't be good. Once again, all this does not explain the 7mm dimension of the canal, which must primarily be due to developmental stenosis. I would have thought that the endplate osteophytes would have been fixed in the ACDF. Since they weren't, I kind of wonder what the point of that surgery was. Of course, we don't have the pre-surgery MRI, so we can't judge.

C7-T1 - Back to the "unfixed" levels. The disk here is protruding quite a bit and indenting the cord. Not good. Oddly, there is no facet/uncovertebral hypertrophy, and hence no foraminal problems.

Last edited by WebDozer; 12-29-2011 at 11:08 AM.

 
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Old 12-29-2011, 11:23 AM   #3
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Re: One Year post ACDF and problems

Of course you have noticed that I keep coming back to your developmental stenosis. That's because I think it's the biggest part of your problem, at least now. Your poor spinal cord is trapped in too narrow a space, and it can't escape when something starts invading that space.

There are three operations that are specifically designed to open up the spinal canal....

Laminectomy - Where the surgeon comes in from behind and removes the bones and ligaments that form the back of the spine, behind the spinal canal. These are the laminas, the spinous process, and the ligamentum flavum. Doing this frees up the cord to move backward, away from all the intrusions. The downside is that some of your cervical spinal stability is lost, especially if very many levels are done. For this reason, laminectomies are sometimes combined with posterior fusions. There are several people on this board who have had this done.

Laminotomy - this is the least drastic of the three surgeries. The surgeon comes in from behind, and shaves off some of the interior of the laminas, thus providing more space for the canal but not compromising spinal stability.

Laminoplasty - There, the surgeon comes from behind, cuts through the lamina on one side and then swings it open, like a door. A piece of donor bone is put in the opening, and the whole thing held together with a titanium strip that is screwed on. The laminoplasty has the advantage of opening up the spinal canal, but preserving spinal stability. It has been done in Japan for decades, but is relatively new in the U.S., so many surgeons have never done one. Also, it involves getting past a lot of muscle that's behind the spine, and this requires great expertise so that those muscles are not damaged.

I would think that any of these surgeries could/should be combined with FORAMINOTOMIES, where the bone growths impinging on the foraminal openings are shave off.

I'm sorry to say that your problems are varied and extensive, and greatly complicated by the developmental stenosis. My guess is that to really comprehensively address your problems that you would need more than one surgery. I could see a laminoplasty combined with foraminotomies, and possibly even a C7-T1 ACDF as well.

You really need to see THREE surgeons for their opinions. I can't stress this enough. And I'd stay away from the guy who did the last surgery.

Good luck, and report back....

Last edited by WebDozer; 12-29-2011 at 11:47 AM.

 
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Old 12-29-2011, 12:39 PM   #4
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Re: One Year post ACDF and problems

Hey Web....someone with a neck almost as bad as mine!!!!! Welcome, Daner51!

Web has done a good job of breaking down the problems you have and yes, you need more surgery and preferably not with whoever did the first one. You can't address your cord problems from the front and it should have been from the back to start with. The disks weren't your problem...the abnormally small canal is.

One of the problems with an ACDF is that they may not be able to remove the entire disk...it may break off and part stay inside....seems perhaps that has happened with you? Seems you have some disks that were supposed to be removed.....but are still there...hmmmm.

I was reading about how they remove the uncovertebral joints and it can be done during an ACDF but obviously wasn't with you and probably should have been. They are very fibrous and can easily be shaved off the vertebra and since you were being fused, they weren't needed for stability anyhow. Seems your doc missed that too.

And why you didn't have foramenotomies all the way down I don't know but again, that can be done from the back.

Hmmm...he left in disks that should have been removed, didn't remove the uncovertebral joints and didn't do any foramenotomies....hhmmmm. And I bet the insurance company paid him some big bucks.

If I were you, I'd head for a big medical center associated with a medical school and see the top spine surgeon(preferably a neurosurgeon) and see if a combination of a laminoplasty with foramenotomies would solve your pain problem. You might not need any kind of fusion beyond what you have as the laminoplasty has some support to it. This would double the size of your canal and open the holes where the nerves come through and relieve a lot of your pain and numbness. I had this exact surgery from C3 to C6 with a decompression of C7 and I woke up with no numbness and no pain(except the surgical pain).

Call around and ask if the doc does the "laminoplasty"...as Web said it's new but it gives the canal a huge amount of room but keeps it protected(a laminectomy leaves the cord unprotected and open to all kinds of injury). And since it's done from the back, the foramenotomies can be easily done.

I suspect you had a doc who just did a lot of ACDF's and may not even know how to do the more complex and difficult new surgeries that are being done. I've met ortho spine docs who do only ACDF's and still call themselves spine surgeons. A real spine surgeon knows how to re-build an entire spine from front, back and sides.

Someone sure goofed on trying to help you....I'm so sorry.

hugs.............Jenny(fused C3 to T1)

 
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Old 12-29-2011, 12:56 PM   #5
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Re: One Year post ACDF and problems

Yeah.... if I didn't make it clear before, I think that the last surgeon likely did the wrong procedure, and may have even done it badly. However, we can't be sure of that w/o seeing the MRI from before that surgery. Maybe the disks were so very badly out of whack at those three levels that even a laminoplasty would not have sufficed.

Still, the complete lack of ANY ATTEMPT to address the developmental stenosis leads me to the same suspicion as Jenny, whcih is that the guy just doesn't know how to do anything else.

Back to my thinking about possibly needing two surgeries.... I'd guess that a C3-6 laminoplasty (combined with foraminotomies) would be #1.Maybe, you could even throw in a laminotomy to widen things up a little at C7. Then, you could follow that up with a C7-T1 ACDF.... IF IT TURNED OUT THAT YOU NEEDED IT.

You might ask, why not just do a laminoplasty from C3 to C7? The answer is that studies have been done about post-laminoplasty neck pain, which seemed to determine that the C7 level is best avoided, just because its spinous process is so important as a muscle anchor. I must add, though, that before I got my C4-6 laminoplasty a few months back, I mentioned this to the surgeon, and he didn't seem to think C7 would be a problem. It may be that over the last several years they have just found ways to do that w/o unduly disturbing the muscles.

One last thing... if your cervical spine is kyphotic (forward-bending), then that is a strong counterindication for laminoplasty, and maybe laminectomy also. The radiologist didn't say you are kyphotic, but he didn't say you are not, either.

Oh, and finally, finally.... keep in mind that I am just an AMATEUR, albeit one with more experience than most people would want.

Last edited by WebDozer; 12-29-2011 at 01:04 PM.

 
Old 12-29-2011, 01:47 PM   #6
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Re: One Year post ACDF and problems

Attached is my original mri, pre-surgery.

I appreciate your help in all this. I'm a rank amateur at this stuff.

I had surgery Jan 2011, went back to work July 2011, but have been off the past 3 weeks (Dec 2011) because of pain. I'm no better than I was 3 weeks ago. I have no clue what to do, what I SHOULD do. I am supposed to see the pain management doctor Jan 3. He's going to want to do injections, facet blocks, etc. I dunno if I can be helped by such things, but if so, I'm game. I am hoping I can at least work. Some sort of a life would be a real nice added bonus!
Attached Images
File Type: gif MRI_page_1.GIF (78.4 KB, 3 views)
File Type: jpg MRI_page_2.jpg (107.4 KB, 2 views)
File Type: gif MRI_page_3.GIF (14.8 KB, 2 views)

Last edited by Daner51; 12-29-2011 at 01:57 PM. Reason: more to the point

 
Old 12-29-2011, 02:25 PM   #7
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Re: One Year post ACDF and problems

That is one really nasty MRI, and it makes it more understandable that the surgeon wanted to do the ACDF's. I don't know, but the minimal superior/inferior (up/down) migration of the disk herniations may be indicative of an ACDF. Could be that a posterior approach would result in those disks migrating even further, and really messing things up? On the other hand, maybe saying the migration is "minimal" is the radiologist's way of saying not to worry about it.

It's odd that the first MRI has so little mention of uncovertable joint and facet hypertrophy, and resulting foraminal narrowing. Could it have gotten that much worse in a year? Is it a different radiologist? (the style of the two reports is quite similar). Was he just paying better attention the second time?

It does seem that the spinal canal/cord has come back a little bit. 4mm was EXTREMELY narrow. Of course, saying that it's 5mm now doesn't necessarily mean it has come back 1mm. Maybe it has just come back a fraction of that.

Still, the canal/cord does NOT seem to have improved as much as it ought to. Is it because the uncovertebral hypertrophy and the osteophytes are keeping it from doing so? I really can't say.

It still seems to me that the developmental stenosis must be addressed. I can't think of any other way to get the cord to rebound to where it should be.

This situation requires that you have INFORMED conversations with three surgeons. It's very important that you be able to show them both MRI's, and clear up why the improvement has not been what it should have been, and what aspects have gotten worse in the last year, and why. Then, the conversation should move to what can be done. Frankly, there are so many things wrong that any number of surgeries could help, but which surgery/surgeries would be best is what needs to be decided.

 
Old 12-29-2011, 03:54 PM   #8
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Re: One Year post ACDF and problems

Thanks! The old jock in me takes some sort of weird pride in the "nasty" comment! I did sort of ignore this injury for as long as I could. Yes, I had times where I went to P.T. over the years, chiropractors, special pillows, you name it. I did not know the extent of my issues back then. I just thought it was arthritis, old age, etc. I had told many doctors over the years about my sore neck, but no one ever did an mri. Lots of xrays, but never anything more diagnostic than that. I certainly had lots of pains in my neck, but I was so busy playing sports, working, raising a family, living, as hard as I could! I just didn't have time to be laid up, for any reason. I don't know what I could have done, to avoid ending up here, anyway. It finally got bad enough that I had to get it fixed, no matter what, and we got an mri done and ended up with acdf surgery.

My wife says this happened because "I have a big ol' head" which is true and also makes me laugh, and that always helps, doesn't it?

I'm going to talk to my doctor about what you have mentioned. I think I need to be real careful, and make sure this is properly addressed. This fusion business makes me nervous because there is no fall back once you're fused. I don't know if the pain management doctor can help me, but I still have that option open to me as well.

I appreciate all the advice. Thank you!

 
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