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    Old 02-17-2011, 10:46 AM   #1
    Laenini
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    Exclamation Help please with MRI?

    Hi All,

    I'm a 45 year old woman who had a C4/5 ACDF in November 2006. While I had some initial relief in my neck pain after that surgery, it was short lived. Scarcely 12 weeks later my symptoms began to return. My neurosurgeon was a jerk and refused to listen to me when I told him I was having problems again. I finally turned to another spine surgeon in Nov/Dec of 2007 for a second opinion. For comparison purposes, here is a copy of the MRI I had during that evaluation:
    Quote:
    CLINICAL INFORMATION: Status post C4-5 ACDF with chronic neck and upper back/shoulder pain, now with swallowing symptoms and increased symptoms. There are no prior studies available for comparison.

    TECHNICAL INFORMATION: Multiple 3 mm sagittal T1-weighted images were obtained in addition to 3 mm T2 MPGR and T2 FSE sagittal and 3 mm axial gradient-echo T2 FSE images.

    INTERPRETATION: Sagittal images show a normal cord and craniocervical junction.

    At C7-T1, the dorsal disc margin is normal and foramina appear patent. Facet joints are normal. There is a disc bulge at T1-2 without central stenosis.

    At C6-7, there is no central or lateral neural compression and facet joints are normal.

    At C5-6, a disc bulge contacts the thecal sac and ventral cord. There is mild chronic left foraminal narrowing and the right nerve root canal is patent. Normal flow signals are present in the vertebral arteries with a right dominant vessel.

    The C4-5 interbody fusion appears solid by MR criteria with no central and lateral stenosis.

    At the supra-adjacent C3-4 level, a small midline disc herniation contacts the ventral surface of the cord. Foramina contact and flatten the ventral surface of the cord. Foramina appear patent and facet joints are unremarkable.

    The C2-3 annular margin is normal and foramina appear patent.

    Facet joints are intact bilaterally.

    CONCLUSION:
    1. A central C3-4 disc herniation contacts and flattens the ventral cord.
    2. A small C5-6 disc herniation abuts the ventral surface of the cord with mild left foraminal narrowing.
    3. Solid-appearing C4-5 interbody fusion by MR criteria with no residual stenosis.
    4. The cord is intrinsically normal without mass or syrinx.
    That neurosurgeon was of the opinion that I would need my fusion extended someday to possibly 3 levels. But he felt that I should put off resorting to a second surgery for as long as possible. He sent me off to pain management and told me to come back when the pm practice couldn't keep me comfortable any longer.

    Flash forward to now:
    I continue to have significant pain and have noticed some other changes that concern me. In particular, I have a lot of trouble doing anything with my hands. They feel clumsy and they cramp up quickly when I try to write or type. I've also noticed that I have a hard time urinating sometimes. Its like I can't initiate and maintain the flow very readily. So I felt it was time to go back to the neurosurgeon for an update. Unfortunately, the NS I saw in Dec 2007 has moved out of the state, so I had to start over with someone new. Here are the MRI results from the exam he ordered:
    Quote:
    EXAM: MRI OF THE CERVICAL SPINE

    CLINICAL INFORMATION: Neck pain with degenerative disc disease and prior cervical fusion. Comparison is made to 12/03/2007.

    TECHNICAL INFORMATION: T1, T2 MPGR T2 FSE and STIR sagittal thin sections through the cervical spine with T2 gradient refocused and T2 FSE axial sections at selected levels.

    INTERPRETATION: Craniovertebral junction structures are unremarkable and no fractures or active inflammatory lesions are identified on STIR images.

    The cord is intrinsically normal without high signal alteration or mass lesion. Flow signals are noted in the vertebral arteries with no paraspinous mass lesions.

    The C2-3 disc margin is normal and foramina appear patent. Facet joints appear within normal limits.

    At C3-4, there is a 3 mm AP diameter central disc herniation indenting the ventral cord. Mild to moderate central stenosis. Foramina appear patent and facet joints are unremarkable.

    At C4-5, the interbody fusion appears solid by MR criteria with no recurrent disc herniation or spinal stenosis.

    At C5-6, disc degeneration is present with degenerative annular bulging and asymmetric right posterolateral 1.5 mm disc protrusion with overall mild central stenosis and mild ventral cord flattening. Foramina appear patent and facet joints are unremarkable.

    C6-7 and C7-T1 levels are negative for disc herniation or stenosis.

    At T1-2, the dorsal disc herniation indents the thecal sac centrally and to the right of midline.

    CONCLUSION:
    1. A 3 mm AP diameter central C3-4 disc herniation indents and deforms the cord with mild to moderate central stenosis. Foramina appear patent.
    2. Mild C5-6 spondylosis with dorsal annular bulging and concurrent 1.5 mm right disc protrusion with cord contact and mild central stenosis.
    3. No recurrent C4-5 disc herniation or stenosis.
    4. Intrinsically normal cervical spinal cord and craniovertebral junction.
    5. Disc protrusion centrally into the right at T1-2.

    Note: The C3-4 disc herniation has enlarged since 12/03/2007. Findings at C5-6 are unchanged.
    Unfortunately, the new neurosurgeon I saw most recently was an even bigger jerk than my first neurosurgeon! I kinda feel right now like I don't know where to turn or what to think.

    I am wondering if some of you who have been down this road more than once in your own lives might have an opinion for me? The newest MRI is now showing stenosis at C3-4. Does stenosis always mean surgery is indicated? Is there a certain degree of stenosis that can be safely lived with? What should my concerns be at this time?

    Any and all opinions are appreciated!
    Thank you!
    Leanne
    __________________
    Ehlers-Danlos Syndrome Type 3
    Scheuermann's Kyphosis, Cobb angle >90 degrees
    Severe DDD with multiple herniations and areas of stenosis, 16 affected disks with many extruded and sequestered disc herniations.
    C4-5 ACDF 2006
    C3-6 ACDF 2013
    C3-6 ACDF REPAIR after failure of fusions, 2017
    Chronic Myofaschial Pain Syndrome
    S/P severe Covid induced ARDS with resulting Pulmonary Fibrosis, oxygen dependent. 2021/2022.

     
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    Old 02-17-2011, 02:11 PM   #2
    jennybyc
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    Re: Help please with MRI?

    HI...I'm Jenny and I am fused from C3 to T1. First I had a surgery to to enlarge the spinal canal to stop stenosis and then 3 months later, broke my neck. I dislocated 5 vertebrae and broke 3 of the new bone grafts that had been put in. So my great new stenosis surgery turned in a long 6 vertebrae fusion from the back. I have some experience with necks.

    One of the things I don't see in your report is how wide the cord is. It does say your cord is indented on the ventral surface(front) and that you have mild to moderate canal stenosis but no measurement. The spinal cord is normally about 11-12 mms wide. My narrowest area(I had cord compression at 4 levels) was down to 6mms and I've seen other MRI's where people have been down to 4mms. Believe it or not, the cord can take a lot of compression if it occurs slowly. I would ask the neurosurgeon how many millimeters your cord is currently and at what point does he think you need to have it decompressed. That will give you an idea of when he would operate. I saw 1 doc who said I should go down to 4mms but the one I finally chose to do surgery wanted to do it at 6mms.

    The reason they wait is that you do have a chance of ending up paralyzed from the surgery.

    Your main problem seems to be at C3-4 but even that is labeled mild to moderate. In medical-eze, they rate the severity of compression as minimal, mild, moderate and severe be it cord or canal or spinal nerves. They usually don't operate until you hit severe.

    The other 2 areas of concern, C5-6 and T1-2 are both mild.

    The good thing though is that all the foramina are patent....that means the hole where the spinal nerves exit are all open and with no compression visible.

    Your hand clumsiness may be from the developing cord compression but it may also be from the damage that had you do a fusion to start with. In a certain percentage of people, surgery does not stop the pain nor does it end the damage. In fact, I just recently read a study that was done where they took DNA samples form people about to undergo spine surgery to see if they could find a genetic link to degenerative disk disease. They didn't. But what they did find is what seems like a genetic link to those who had continued pain after surgery and those who were pain free. No one knows why so the study has been widened. It could just be that for some, once a nerve is damaged, it just doesn't recover and for others, the nerves do recover.

    What is causing you pain and problems could be the new stuff but could also be the old damage just telling you it's still there. When I broke my neck, I was in a lot of pain but also had mixed paralysis. Most of the paralysis went away and I got movement and feeling back but some 3 years later, the tendons in those areas affected by paralysis, have all gone lax and my joints dislocate as a result. And there is nothing they can do......we thought it was healed and it was but only to a certain extent. Some nerves appeared to be healed but couldn't hold on and eventually died back.

    See a spine surgeon(ortho or neuro) at a major teaching hospital...they know the most and they teach it. This is one time when you want and need the best. That is the best thing any of us can do...find a great doc and stick with them.

    Hope this helps explain some of your problems.

    gentle hugs..............Jenny

     
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    Laenini (02-18-2011)
    Old 02-17-2011, 07:35 PM   #3
    Laenini
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    Re: Help please with MRI?

    Thank you for the help, Jenny! I'm curious, is the size of the herniation proportional to the extent of the compression? In other words, if my herniation is 3mm, does that mean that my cord is (11 mm-3 mm = 8 mm) wide? I'm probably oversimplifying the issue, but I can't visualize the affected anatomy well enough to answer that question myself.

    Jenny, you sound as if you have an amazing story to tell. I would enjoy hearing more about your neck problems and your recovery. Do you have a blog or anything where you have told your story in greater detail?
    __________________
    Ehlers-Danlos Syndrome Type 3
    Scheuermann's Kyphosis, Cobb angle >90 degrees
    Severe DDD with multiple herniations and areas of stenosis, 16 affected disks with many extruded and sequestered disc herniations.
    C4-5 ACDF 2006
    C3-6 ACDF 2013
    C3-6 ACDF REPAIR after failure of fusions, 2017
    Chronic Myofaschial Pain Syndrome
    S/P severe Covid induced ARDS with resulting Pulmonary Fibrosis, oxygen dependent. 2021/2022.

     
    Old 02-18-2011, 10:01 AM   #4
    jennybyc
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    Re: Help please with MRI?

    Anatomy wise, the disk is way in the front of the vertebra and actually between the vertebrae. The spinal canal and spinal cord are way in the back so they don't actually come in contact except when a disk ruptures. So no, there is no correlation between the amount of "oozing" of the inside disk material and the amount of compression of the spinal cord.

    Disks can rupture and go frontwards, sideways or backwards and yours just so happened to go backwards toward the cord. I had one level where my cord looked like a ******* pancake! The ruptured disk had made it flat on one side and spinal stenosis made it flat on the other side(stenosis is where the bone of the canal thickens for unknown reasons). Should be oval, not a pancake!

    No, I don't have any kind of blog or web page. I'm pushing 60 and have just about enough knowledge to post on a website and send emails. Not tech savvy at all! But unlike my hubby, I do know which button to push to turn on the computer.

    take care.............Jenny

     
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