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  • Cervical SPINE MRI results , help interpret please

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    Old 05-01-2015, 09:23 PM   #1
    June2015
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    Smile Cervical SPINE MRI results , help interpret please

    Hi everyone ,

    Wondering if anyone can help interpret my cervical spine MRI please .

    I am 9 months post ACDF surgery with an intraop spinal cord injury and lack of any fusion . I have been told I need revision posterior cervical spine fusion to correct my problem. In the interim I have severe un- subsiding posterior neck pain and daily headaches . I have multiple restrictions due to cord injury with lack of any signs of fusion ( radiographs , MRI , CT scheduled upcoming week) .

    Here are some important details regarding my situation . ACDF (C5-C7 with Medtronic premier anterior titanium plate and Titan interbody spacers ) . Preop diagnosis was disc herniation at C5-C6 and bulging disc C6-C7 no myelopathy. Unfortunately , intraop, my cord was injured ( neuromonitoring all normal at baseline preop immed prior to incision then loss of MEP unilaterally on right side) Surgeon diagnosed me with central cord syndrome ( I am 35 yrs old ,thin ,athletic ,non smoker healthy , and worked full time up until surgery ) . Luckily I have made improvement but have significant neuro issues ( hyper reflexive 3+ , weakness to right side , decreased coordination ) Now I am facing non-Union / pseudoarthrodesis and need revision surgery ( scheduled in a month posterior)

    I have a new MRI that states the following in impressions. The report states : dorsal disc osteophyte at the C5-C6 level, effaces the ventral CSF space but does not compress the cord . focal myelomalacia is noted within the right side of the cord at this site , with decrease in T2 hyper intense signal compared to prior MRI . There are a few perineural cysts within the lower cervical and upper thoracic spine of questionable significance visualized on prior MRI .

    I am so scared to undergo another surgery and come out with more neuro deficits . I am hoping to try and understand everything in as much detail so I can better prepare myself . Please let me know if anyone has any thoughts on this or has had any similar experiences . Any and all input is greatly appreciated .
    Sincerely ,

    June

     
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    Old 05-02-2015, 09:51 PM   #2
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    Re: Cervical SPINE MRI results , help interpret please

    Hello and welcome to the board.

    There is a lot going on in your post.

    I'm assuming the prior mri they are talking about is the one pre-surgery. This means that the damage done during surgery is most likely seen in the new mri as focal myelomalacia. That is most likely what is causing your "cord syndrome" symptoms. Myelomalacia can improve but it does not always.

    The mri also mentions a disc osteophyte effacing the csf space at c5/c6. They don't say if it was there in the previous mri or not but to get large enough to efface the csf space I would guess it was. If so I would question why it wasn't removed in the surgery.

    Do I have it right that you are diagnosed with pseudoarthrodesis without radiographic evidence of non-fusion? If that is so how are they determining you have this? From what I've read its not terribly uncommon to be incompletely fused after 9 months (although there would generally be some growth by that time).

    If revision surgery is indeed indicated it would often be done posteriorly. The main problem there is that these surgeries are.known to cause persistent posterior neck pain. So not only is the planned surgery unlikely to alleviate your pain, it may actually increase it.

    Is the surgeon scheduled to do the revision surgery the same that did the original surgery? It seems that there were several things that went wrong in that surgery so I would be hesitant. At any rate I would consider a second opinion with a skilled spine specialist to review the current situation and get recommendations. It may be difficult to get someone to look at such a rent surgery by another surgeon. Sometimes teaching hospitals have spine specialists that are more willing and familair with giving opinions when another surgery is involved.

    Good luck and let us know how you get on...

    Last edited by ChuckStr; 05-02-2015 at 09:54 PM.

     
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    Old 05-02-2015, 11:50 PM   #3
    June2015
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    Smile Re: Cervical SPINE MRI results , help interpret please

    Thank you very much for responding to my post . I truly value everyone's input and appreciate that there are others that with similar and related experiences we can all learn from .
    To clarify first post / questions the Non-Union or pseudoarthrodesis has been evaluated by serial radiographs over the past 5 months without any evidence of any bone growth at all . I am fortunate to of found a wonderful orthospine surgeon to of taken over my case within a few months of the first surgery . The latest rads on flexion / extension lateral views along with neutral comparisons indicate instability / joint movement posterior at same level C5-C7 with c5-6 most affected . I did also go for a second opinion in NYC for the last MRI and a surgery consult in NYC also . This surgeon agrees there is not any evident fusion and surgery is needed ... He wants to confirm surgical approach with a CT closer to surgical date to determine approach , he said posterior if any pseudoarthrodesis is present or anterior complete revision with plate and implant removal / replacement if there is not any pseudo bone present at all .
    I have not returned to initial surgeon after I encountered blatant serious discrepancies in the factual details of the intraoperative events as reported by himself in his operative report when compared to the intraoperative neuromonitoring report with corresponding data and event log ( surgeon declined all MEPS intraoperatively for the first 90 minutes of surgery , he only obtained Preop baselines that were normal and reproducible bilaterally but then when he allowed acquisition after he was practically finished with the entire surgery , after all trials of interbody spacers were completed and the two level titanium interbody spacers were placed in final position with allograft did he first allow / obtain intraop MEPS , by this point i had lost all unilateral right side MEPS both upper and lower and they did not return Intraoperatively . In addition he performed a wake up test on me which I was not prepared for preoperatively , and I unfortunatley have a lot of recall of the surgical events ( I wasn't given any benzodiazepines for amnesia ) and only given TIVA ( propofol / some remi fentanyl IV as bolus ex with only oxygen provided via endotracheal,tube . The wake up test is also documented on my neuromonitoring reports but omitted in operative and anesthesia reports . There are many disturbing discrepancies I have found . I initially told family members of the wake up test and recall and sadly no one believed me ( they thought I must of been given ketamine intraop and was describing a dissociative experience and that the details I knew could not actually be correct .. Then when I finally was able to obtain a copy of the IONM directly from the contracted neuromonitoring company everything I recalled was supported in th data from the actual report . All my intraop Flouro is also "missing " not in my records and unable to be located by hospital,or surgeon ( I requested it for the next surgeon to have avail in case they need it for planning the revision ) .
    The above details were horrific to live through , have memories of and I cannot go through this trauma again physically or mentally . I truly need some help here from everyone / anyone that has any experience with what I have described because I cannot have another worse outcome upon OR exit and hospital discharge than what I came in with . My present symptoms do include relentless posterior neck pain since surgery in September worse pain in flexion / extension feels better only when neutral,or in soft collar / brace , headaches that start in back of neck and resonate bilateral sides of head , clumsiness , weakness right hand , decreased coordination hands . I agree the large osteophytes should of been removed at surgery, wondering if the spinal,cord area of focal myelomalacia was a possible instrument tear during same level,discectomy into cord and CSF leak may of prevented removal of the osteophyte ? ?
    Has anyone had an intraop cord injury then needed revision within the year of their first surgery ? Has anyone had a spinal cord injury and not fused ? Has anyone had to have all their instrumentation removed / replaced for complete non-Union / failure ? Which is the safer / less risk to cord that would provide best chance for stability and fusion ? Has anyone had a wake up,test with recall ? I am also concerned that the plate he used ( Medtronic premier anterior plate is no longer in distribution by the company is sold used / refurbished online not from the manufacturer . Could it be a faulty instrumentation issue ? Also worried about my statistically uncanny bad luck ( 0.1% risk of cord injury , 3% chance of non-Union with instrumentation at two levels ) . Does anyone have any other suggestions ? I truly want to heal up,as best as possible and try to move forward in a hopefully less painful state .

     
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    Old 05-03-2015, 12:56 PM   #4
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    Re: Cervical SPINE MRI results , help interpret please

    Wow that sounds like a horrific experience and I'm sorry you went through it. As you know since you mentioned the statistical probabilities of these events, your situation is very, very far from the norm. The approach you described from your current surgeon seems sound.

    It is pretty common to have complete hardware removal on revision surgery and I have heard of switching to posterior surgy when there is instability involved. From what I've read neither surgery is inherently safer. They both have many similar risks and a few individual ones such as some degree of swallowing issues with anterior surgery and some degree of neck pain with posterior.

    I've never heard of anyone having a spinal cord injury and not fusing at all. Instrument injury us possible but at any rate you didn't have myelomalacia and then after surgery you did. And then there was the wakeup event. All that taken together sounds like a pretty bad surgery. I'm not sure that I would look at that as bad luck. Those statistics are compiled from all the surgeries in the us. It does not mean the figures hold for each individual surgeon. My surgeon here keeps his own records and he hasn't had a spinal cord injury in over 4000 surgeries. My suspicion, and this is just opinion, not fact, is that there are a few stellar surgeons, lots of good ones and a small number of not so good ones that make those kinds of figures higher.

    I had a friend that had congenital stenosis who had several fusion surgeries. The last one she had done she woke up and remembers screaming. I don't know if it was from a wake up test or just improper anesthesia.

    Many people say on these boards the most important choice after choosing surgery in the first place is the choice of surgeon. Your current surgeon has a sound plan but if you have not done so, I would try to investigate as much him as much as possible. You can find info on any sanctions, malpractice etc online in addition to opinions of those who have uses him. You may also be able to find out information about how many surgeries etc he has done.

    I wish you the very best of luck with your revision surgery. Please keep us up to date on how everything goes...

     
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