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MRI report. Is surgery really needed? I have Cervical Dystonia + spine issues


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Old 05-14-2018, 05:59 PM   #1
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MRI report. Is surgery really needed? I have Cervical Dystonia + spine issues

Hello all!
I have lurked for a while but I’d like to share my MRI results (past and present). I was diagnosed with Spasmodic Torticollis in 2008 after two years of suffering from horrible seizure like “episodes”. Apparently I have cluster headaches which the cause is my Cervical Dystonia. I am allergic to all Triptans so I started Botox therapy which has helped some. Not always as with most treatments.

Last year in January I started having an enlarged dorsocervical fat pad which caused some alarm and started limiting ROM and then neck pain started up pretty bad. I got imaging done which didn’t show any signs of cancer which was great, but my neck pain was pretty bad so off to PT I went.

I did several months (6-8) of land and aquatic PT as well many NSAIDs and also did two cervical ESI’s and one nerve block. The nerve block wasn’t done with any steroids as I had just gotten two injections within 3 weeks of that. It did help. Not sure if it was the combination of the right location of the steroids and the followed nerve block or just the block itself but the SNRB helped me for about 4 months.

I had a lot of cluster headaches over the years with bouts of remission. I was in a remission period during the above mentioned times; and then started coming out it. I spent a few months trying to get a doctor in the state I was in (OK) to do Botox injections but nobody was available or able till right about the time I got my c-spine injections. They didn’t help. I got a second round in October once I came back to CA and was able to see my neurologist that I’d seen since 08. They still didn’t help, so I scheduled to see a Pain Management doctor so I could set up another nerve block. Apparently I ended up with a neurosurgeon who wanted to do a multi level ACDF surgery. Though he did say if I wanted to try conservative measures I was happy to do so. I did feel pressured to get on his surgery calendar and I was put off by his comment about me being a “perfect candidate” for the ACDF. This alarmed me only because the doctor I saw in OK just a few months prior at the spine hospital, who was highly rated, said flat out “you’re too young - it isn’t that bad and I won’t operate on you.” He basically told me to do injections and conservative treatments but if I wanted full ROM which I should be able to achieve, then fusion isn’t doing that.

So I have two doctors (only one I really felt confident about) with advise that was counter to the others. Also I should mention that this CA neurosurgeon did not request nor did he think I needed new imaging. Seeing as I had just had an MRI in July 2017, and this was January 2018.

So I pushed off any surgery, busted my hump with months of PT, and put off doing any additional injections as I gained a lot of weight from the steroids but more importantly I was able to achieve relief from nerve pain when I got my January Botox injections after seeing the neurosurgeon. I had less weakness (present when I saw the CA neurosurgeon), and better ROM. I was due for my next round of Botox but mistook the date and went in 3/19 instead of going in April, I explained in the appointment I had some headaches and a pinch here and there in my neck. Two cluster headache series that month and my doctor gave me some “waste” from his last patient which was about 20units in my neck.

I went back April 11th as scheduled and he gave me 150units in my neck which normally he said was 120. I had what some refer to as Dropped Head Syndrome. Basically my neck muscles were extremely weak from having too much Botox. I had a lot of pressure type headaches and was in a lot of pain. ROM was limited again, pain present, and PT wasn’t effective (even doing some Graston work). Eventually I went in for a Toradol injection which offered some relief but wasn’t able to take the oral meds so my neurologist prescribed me the injectable form to self administer at home if/when needed for up to 5 days. I only did two of them but got some relief. He also ordered a new MRI. I felt like he did the latter to cover his butt in regards to the Botox injections since I wasn’t scheduled to receive them but he gave me some to reduce the pain I had. He also sent me an email about the findings which affirmed this in my opinion.

The results are below. He made it clear that my “disease has worsened and conservative methods have proven ineffective” so suggested I get in touch with my neurosurgeon ASAP as my findings we worrisome in his opinion, and wished me “good luck”.

I am now scheduled for a follow-up visit with my neurosurgeon in CA next week but I am looking into possibly a private practice spine center for a second opinion. Or perhaps will even contact my old doctor in OK and ask him what he thinks.

I’d appreciate any input you all have to offer on not only my case, but also my MRI results. Thanks so much and sorry for the long post.



MRI June 2017:

PROCEDURE: MRI CERVICAL WO CONTRAST REASON FOR STUDY: Chronic neck pain, Chronic neck pain, Cervical radiculitis

PROCEDURE DATE: 6/27/2017 9:33 AM COMPARISON: None.

Straightening upper cervical spine. No subluxations. Vertebral body heights are normal. Bone marrow signal intensity is within normal limits.

Multilevel small anterior endplate osteophytes, most pronounced at the C5-C6 and C6-C7 levels, and posterior disc osteophyte complexes most pronounced at the C3-C4, C4-C5 and C6-C7 levels.
There is indentation of the ventral thecal sac with relatively mild spinal canal narrowing most pronounced ventrally on the right at C3-C4. There is no spinal cord compression.

Disc osteophyte complexes and uncovertebral joint hypertrophy contribute to moderate narrowing of the right C4-C5 neuroforamen, with mild encroachment upon the right C3-C4, left C4-C5, and bilateral C6-C7 neuroforamina as well. Imaged spinal cord is normal in caliber and signal intensity.

IMPRESSION IMPRESSION: Cervical spondylosis resulting in relatively mild spinal canal narrowing most pronounced at C3-C4, and multilevel bilateral neuroforaminal narrowing which is most pronounced on the right at C4-C5.

MRI May 2018:

MR CERVICAL SPINE WITHOUT CONTRAST 5/3/2018 9:32 PM
CLINICAL HISTORY: Neck pain
COMPARISON: MRI 7/15/2017.
 
TECHNIQUE: 3T MR imaging of the cervical spine without intravenous contrast
 
FINDINGS:
 
Disc degeneration from C3-C4 down to C6-C7. Compared to 7/15/2017, there is increased protrusion at C3-C4 where there was no effect on the cord previously, now demonstrates complete effacement of the ventral CSF space and ventral indentation of the cervical cord, without associated cord signal abnormality. Disc disease in the remaining levels is stable.
 
Vertebral bodies are normal in height and alignment. Marrow signal normal.
 
The following axial levels are detailed below:
 
C2-C3: Unremarkable. 
C3-C4: Enlarged disc protrusion paracentral to the right, effacing the ventral CSF space and indenting on the ventral cord, causing mild canal stenosis and mild right lateral recess stenosis. Without contrast, it cannot be determined whether part of this protrusion is granulation tissue second to an inflammatory response to the protruded disc.
 
C4-C5: Stable disc protrusion and right uncovertebral spurring, causing moderate right lateral recess and neuroforaminal stenosis. No canal stenosis.
 
C5-C6: Stable disc protrusion.
C6-C7: Disc protrusion causing mild canal stenosis, effacement of the ventral CSF space and mild right neuroforaminal stenosis.
 
C7-T1: Unremarkable.
 Other findings: None.
 
 
IMPRESSION:
 
1. Stable exam with multilevel cervical disc degeneration, with increased disc protrusion at C3-C4 causing ventral indentation on the cord. No cord signal abnormality.

 
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Old 05-14-2018, 07:26 PM   #2
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Re: MRI report. Is surgery really needed? I have Cervical Dystonia + spine issues

First, as you have found, you will get different opinions depending on what part of the country you are from. Well, maybe not "different" but the threshold for the need for surgery will be different.

A lot of spine surgery revolves around the individual surgeon's education, training and experience. It isn't like many other surgeries where things are more obvious -- the appendix is diseased and needs to come out, for example...or a test reveals a heart valve needs replacing.

With spine surgery, a lot of it is a judgement call. When I had my first lumbar surgery, I had opinions ranging from the need to fuse one level all the way up to five levels!! A Huge variation!

The fact that you went from nothing impinging on the spinal cord at C3-4 to, less than a year later, having compression on the thecal sac that contains the spinal fluid and some degree of compression of the spinal cord, indicates that you need this issue to be watched! It could also be that the MRIs were done in two different locations and were read
by two different doctors...so possibly, this might account for some of the change...although one would hope not!!

There were not changes in the other segment levels such as this. "Stable disc protrusion" pretty much means that it isn't worse than it was back in 2017...it has not gotten worse or the disease has not progressed.

Keep in mind that all the stenosis is judged to be mild ( this on a scale that goes minimal, mild, moderate and severe.). Minimal, mild and sometimes moderate almost always can be treated with conservative methods. Nerve compression is not considered severe enough to require surgery.

Now, I'm just going off the MRI report which is just one piece of the puzzle. The spine surgeon usually doesn't even read the report but looks at the images and forms his own conclusions. They will also perform a physical exam and a basic neurological exam, as well as taking a patient history to learn how these symptoms impact your life. This information will be correlated to what is found on the MRI and will then be used to help the surgeon determine a diagnosis and plan for treatment.

 
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