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xcobra 09-27-2012 10:08 PM

Severe cervical spinal stenosis
 
Hello - This is my first post and hope to gain more knowledge from those who have experience with my particular issues. I have had a previous ACDF C5-6,7 in 2005 (osteophyte penetration of sac with loss of CSF, severe radiculopathy left side of neck down to left hand) and a foramenotomy C7-T1 in 2008 (gradual complete numbness of right ring and little finger). Lingering pain caused referral from my NS to a Pain Management doc who has been treating me since 2010. (My NS said if he had to operate again, he would have to fuse my entire neck.) I have had difficulty in swallowing since first operation that has increased markedly since Jan 2012. PM doc wanted to do cervical MRI with and without contrast, however, my Cigna insurance would only authorize MRI without. Both PM doc and imaging folks wanted to do both MRIs because of the instrumentation in my neck from the ACDF and compare studies. Finally got a CT scan done and went over it last Friday, 9/21, with the PM's PA. Basically severe stenosis, down to 8mm at several points and moderate to severe damage to each vertebral level. (Earlier imaging in 2010 had shown mild to moderate damage and the first mention ever of congenital stenosis).
I kind of tuned out from shock when I heard 8mm at several points and, perhaps I misheard, but I think I heard him say myelomalasia (sp) or something close to it. I asked him what that was and he said something like an issue that could cause multiple problems. I have been trying to read up on these issues this week and plan on trying to see him tomorrow and if nothing else get a copy of my CT report.
So what I would like to know is if someone has had similar experiences and if 8mm is a danger point, or am I being overly concerned?
Thanks for your consideration!

ladybud 09-27-2012 11:56 PM

Re: Severe cervical spinal stenosis
 
It depends on whether that stenosis is central of the spinal cord canal or stenosis of the foramen where the nerves emerge on either side of spine. It also depends on what your symptoms are and how severe. That is quite tight for the cord, but not so for the foramen. Cigna is being ridiculous and I would appeal their decision with a letter of explanation from your Dr. The swallowing trouble is likely from scar tissue from previous surgery, and scar tissue shows up best with contrast. If you have to have surgery again, they could perhaps remove the scar tissue pressing on esophagus, but of course, need to know where it is, hence the necessity of the contrast. Appeals often work, if they understand the rationale. An enlarged thyroid could be causing the swallowing problem, so your thyroid should be checked by physical exam at least so no faulty assumptions are being made. The myelomalacia refers to softening of the spinal cord from compression and lack of oxygen due to compression of the blood supply. If the report says myelopathy, that is also an indication that the cord compression is causing lack of oxygen to the cord which can cause permanent damage. This is accompanied by pain, numbness, tingling, burning weakness in the arms especially or clumsiness of hands. This is more urgent to avoid permanent cord damage. A somato-sensory evoked potential test can clarify whether myelopathy exists if symptoms are vague or intermittent.

WebDozer 09-28-2012 09:19 AM

Re: Severe cervical spinal stenosis
 
The answer to your question about 8mm is, "could be bad, but not necessarily". I was down to 5mm not long ago. Take a look at my MRI from before a 3-level laminoplasty last year:

http://www.healthboards.com/boards/spinal-cord-disorders/904688-my-pre-laminoplasty-mri.html

Also note the "short pedicles" observation. This is likely also part of your problem, in that short pedicles would be one of the components of congenital stenosis. Laminoplasties were really designed for people with congenital spinal canal stenosis, in that they directly address the central problem, which is that you just don't have enough room to start out with.

xcobra 09-28-2012 09:39 AM

Re: Severe cervical spinal stenosis
 
Ladybud - Thank you for your reply! We appealed twice about the MRI with contrast; they would not back off their guidelines. With the CT showing some problems, maybe it will be different this time. I am going to ask the PM doc to refer me back to my NS for eval. Maybe there will be a chance Cigna will allow both MRIs if he orderd it (there seems to be some weasle wording about a specialist being able to do more than the original requestor. Of course, he is also a specialist, so who knows).
I have had my thyroid checked very recently, and the lab results indicated normal. Pain in neck and shoulders/biceps area is sometimes severe and wakes me up at night, but is not constant. Trying to find a comfortable position is difficult also. The pain is not as bad as it was prior to my original surgery in 05, but severity, duration, and frequency are all increasing. I have noticed increasing balance problems, no dizziness, just having to regain balance sometimes as I turn around or when I just close my eyes like when showering. I haven't noticed any real clumsiness in my hands, although there are times when my right hand/fingers "contract" or pull inwards together like a charley horse (?). Also some unconscious finger stiffening. So I don't know if this is a tempest in a teapot or if I really have a problem.

xcobra 09-28-2012 10:01 AM

Re: Severe cervical spinal stenosis
 
Thanks Webdozer! I have seen several of your posts and they have been very informative. Seeing what so many people have and are suffering and the support received from these boards is what made me finally decide to post instead of just lurking. From what I understand, my stenosis is central although there may very well be foraminal stenosis at several at several levels also. My second operation dealt with that at C7-T1. It is also my recollection that the severe stenosis was at several central levels, some high and some lower cervically speaking. As I stated earlier, my cervical spine is a mess! And I know I have damage at the level above my C5-6,7 fusion which I understand is a pretty common consequence of fusion. What I don't understand is who is right in the question of the MRIs. Is my PM doc correct (along with the imaging folks) in needing both an MRI without contrast and one with contrast because of the presence of the fusion, or are the CIGNA guidelines correct is stating that an MRI without contrast is sufficient?
I have been told to expect to be in pain the rest of my life and I can accept that, but my problem when do I start worrying that something needs to be done?

WebDozer 09-28-2012 10:05 AM

Re: Severe cervical spinal stenosis
 
Sorry, I can't help with the contrast question. I'd suggest getting other opinions about what can be done for you, surgery-wise. The problem with laminoplasties are that insurance companies don't seem to like them, even though they've been around 20+ years.

nochange 09-29-2012 01:50 PM

Re: Severe cervical spinal stenosis
 
[QUOTE=xcobra;5063545]
I have been told to expect to be in pain the rest of my life and I can accept that, but my problem when do I start worrying that something needs to be done?[/QUOTE]
You have been told that, huh?. Well, isn't it nice that doctors cannot cure chronic neck pain, huh?. There is nothing they can do about it. Once you have neck pain that's it. It is FOR LIFE. With all the new "invention" and technology they just cannot cure chronic neck pain.

Trying to find a comfortable position to sleep is difficult? tell me about that.
WHen it comes to neck, it can get worse and even a surgery will not help you with this issue. You may find yourself one day and every day cannot find a comfortable position to rest your neck, not just once in a while. Be ready for that.

How were you injured by the way, car accident?

ladybud 09-29-2012 05:53 PM

Re: Severe cervical spinal stenosis
 
I would believe your Drs about the contrast being needed. Cigna is probably just trying to save themselves money. They are not knowledgable about all these medical things, and a one size fits all approach is not what you need. Your Drs have nothing to gain but better information to help you.

xcobra 09-29-2012 09:05 PM

Re: Severe cervical spinal stenosis
 
nochange - No accident/injury, though flying helicopters and jumping out of perfectly good airplanes probably didn't help. In 2005, my left arm gradually began hurting more and more from neck to forearm, some really severe pain. They checked out my heart first, then sent me to a NS and he did some imaging. Images found an osteophyte impinging the cord and surgery found it had pierced it and I was leaking CSF. I wound up with an ACDF.

nochange 09-29-2012 10:19 PM

Re: Severe cervical spinal stenosis
 
xcobra, so you probably had a whiplash and you just didn't notice that at that time.
Isn't it awful to not being able to rest your neck on the pillow?. Trying and trying to find a comfortable position to rest your neck on the pillow. What will you do when you won't be able to do that?

xcobra 10-01-2012 01:52 PM

Re: Severe cervical spinal stenosis
 
Well, I finally was able to get a copy of my CT report that the Pain Management PA read to me on 21 Sep. Unfortunately what he read doesn't necessarily jive with what he related to me unless he was inferring from his experience. But I still haven't heard from his office about referral request from last Friday (9/28). Here is my Report:

"CT Cervical Spine

INDICATION: Cervical Radiculopathy

TECHNIQUE: Axial images performed through the cervical spine without IV contrast. Sagittal and coronal reformmated images were obtained.

FINDINGS: There has been anterior cervical fusion from C5 through C7. There is solid bony fusion acros these levels without surgical hardware complication. Degenerative disc disease is present in the remainder of the cervical levels with endplate osteophyte formation noted.

At the C3-C4 and C4-C5 levels posterior ostephytes result in stenosis. The stenosis is at least moderate with bony narrowing resulting ina a maximum canal diameter of 8mm. However, superimposed disc disease could increase the stenosis but would not be detected by this modality.

At C2-C3 there is significant left foraminal stenosis sceondary to facet joint hypertrophy and a posterolateralosteophyte. There is also significant foraminal stenosis at the C3-C4and C4-C5 levels.

There is no fracture in the cervical spine. Thealignment is normal. The paraspinous soft tissues are unremarkable. The lung apices are within normal limits.

IMPRESSION: No acute findings in the cervical spine. There is multilevel degenerative disc disease with at least moderate stenosis in the mid and upper cervical spine."

Note that there is no mention specifcally of "severe" stenosis (though it does say "at least moderate") or "myelomalacia" that he said as he was discussing the report with me. So I am confused as to whether I have a problem or not when I compare what is written to what I was told. My concern is with the 8mm maximum canal diamter at C3-C4and C4-C5 and how myelomalacia even was mentioned, unless his experience shows a connection with the stenosis I have and what has typically been found myelomalacia-wise.

Do I have a significant problem? Thanks for any insight!

WebDozer 10-01-2012 02:15 PM

Re: Severe cervical spinal stenosis
 
Given that the central stenosis is "at least moderate" (which means, "it might be severe"), and the radiologist's uncertainty is due to the modality (I assume he means that it's a CT and not an MRI), it would certainly seem that you need a better image, which I guess means an MRI.

The foraminal stenosis at C2-3 could, I think, be rather easily fixed by a foraminotomy. I think you need to get a better idea of C3-5 before going into it further. I'd also suggest reading up on laminoplasty, which i think might be your best option, although I have my doubts about insurance paying for it.

Hopefully, you can get a better image, and a follow-up with a spine surgeon...

xcobra 10-01-2012 03:12 PM

Re: Severe cervical spinal stenosis
 
Yes, WebDozer, I think you're absolutely correct. An MRI is certainly justified IMHO to see how bad the stenosis at C3-5 really is. Now if I could only get the Pain Management folks to return my call... What's the deal with laminoplasty and insurance companies, anyway?
BTW, It seems to me that I have seen or heard in my quest for information over the years that neck pain alone is insufficient grounds for having surgery. There has to be some type of pain radiated to the extremities, shoulder blades, etc. I only bring that up because I have seen that idea discussed in other threads. I have some pretty bad pains in my neck (other than the people I work with and my inlaws :-) ) as well as down into my shoulders/biceps (usually my left, but occasionally my right also) and sharply into my left hand (ring and little fingers).

WebDozer 10-01-2012 04:44 PM

Re: Severe cervical spinal stenosis
 
Maybe I'm not being fair to the insurers w/r/t laminoplasties. Where I live, we have the best surgeons, but they don't belong to Blue Cross, which is what I'm stuck with. So for my last two surgeries I had to pay the surgeon out of pocket. Fortunately, Blue Cross still paid for the hospital, which was a much bigger bill.

It could be that laminoplasties are just harder to do than laminectomies. There also used to be a problem with doing a laminoplasty of the C7, due to disruption of neck muscles, but I don't see why that wouldn't also apply to laminectomies.

xcobra 10-05-2012 12:08 PM

Re: Severe cervical spinal stenosis
 
Well, I have talked to the Pain Management staff over the last several days to get an idea where I stand. Even though there is significant stenosis at C3-5, there doesn't seem to be any emergent risk so the PM doc feels no compelling reason to to be referred back to my NS yet. We do want to find out how much narrower the canal is, if at all. The CT report indicates a possibility of increased narrowness so might as well find out about it. My PM doc wants to make sure we go down the right path and not do anything precipitously. We all agree that another try for Cigna to authorize an MRI without contrast is warranted, although the same misgivings as before apply as to whether all the necessary data will be obtained without an MRI with contrast also. Perhaps if the MRI without contrast still is lacking in some important details, Cigna may be convinced to authorize the other. All we can do is try. I am waiting now for a call to hear about a scheduling appointment.


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