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    Old 05-28-2013, 03:11 PM   #1
    Silverfae
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    Cervical MRI and surgery

    Hello all-

    I have been seeing about a billion different docs over the past 6 months (it sure feels that way, anyway! for what started out, I thought, as some innocuous tingling in my hands. 2 months in wrist braces and an EMG later, they started questioning if it was my neck and not my wrists or elbows. They finally ordered an MRI last month and this is what they found:

    MRI CERVICAL SPINE W/O CONTRAST
    INDICATION
    A 33-year-old female with neck pain and bilateral hand numbness.
    TECHNIQUE
    Sagittal T1, T2, inversion recovery, and axial 3D and gradient-echo
    T2*, and T1 MR images of the cervical spine. No comparison.
    FINDINGS
    Cervical alignment and marrow signal are normal. There is cervical
    cord abutment and increased T2 signal within the cord from C3
    through C5 compatible with cervical myelomalacia secondary to disk
    degeneration and ventral abutment as detailed below.
    Craniocervical junctional anatomy is unremarkable as is C2-3.
    C3-4 has moderate central canal stenosis with a mild posterior disk
    bulge abutting and flattening the ventral aspect of the cervical
    cord. Uncovertebral spurring encroaches the neural foramina.
    C4-5 has moderate posterior osteophyte-disk complex and mild
    uncovertebral spurring with ventral abutment, and flattening of the
    cervical cord, and moderate central canal stenosis. Neural foramina
    are mildly encroached.
    C5-6 has mild uncovertebral spurring and mild posterior disk bulge
    causing mild central canal stenosis. No cord abutment or
    compression.
    C6-7 and C7-T1 levels are unremarkable.
    Paraspinal soft tissues and musculature are unremarkable.
    Visualized posterior fossa is unremarkable. Cerebellar tonsils are
    normal in position.
    IMPRESSION
    Moderate C3-4, C4-5 and to a lesser extent C5-6 degenerative disk
    disease. Mild to moderate posterior osteophyte-disk complex and
    disk bulging cause moderate central canal stenoses, primarily at C3-
    4 and C4-5, with signs of cervical myelomalacia.
    I suspect there is underlying degree of short pedicles and
    congenital narrowing of the central canal.

    I have had years of neck pain following a whiplash injury to my neck - most of the time, the pain is not unbearale, though i do always have some degree of limited range of motion, but about once a month i have an episode that lasts for 7 or 8 days where i can't move my neck or sleep. My dr had been prescribing me 5mg flexeril tabs 1x per day and 800 mg ibuprofen, neither of which did much for the pain. I also get pain that radiates down both my arms, along with periodic severe pain in my hips and low back (where they discovered a herniated disc) and pins and needles in my legs and feet - because of all this pain, I was slapped with a fibromyalgia diagnosis years ago and everyone has ignored me when I said I had pain until now. I saw my orthopedic surgeon after the MRI and he said I had a lot of damage but that it could be vitamin deficiency or thyroid issues causing the pins and needles and sent me for a neurology consult.

    So today I saw the neurologist and he said my symptoms were certainly from my neck and that I definitely need surgery soon and that with the bruise on my spinal cord if I were to sustain a whiplash injury now I would likely be completely paralyzed - he also said that the discs in my neck in combination with the congenital stenosis is actively da,aging my spinal cord and if I don't have surgery I could wake up and be partially or fully paralyzed at some point, just from living.

    I am trying to get my GP to make a referral to a neurosurgeon but she seems to be dragging her feet. This is all happening very quickly for me so I am looking for some advice/support from people who have been there before.

    Thanks.

    Jessica

     
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    Old 05-28-2013, 09:15 PM   #2
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    Re: Cervical MRI and surgery

    First of all I would suggest you find a different orthopedic surgeon. I assume this person was not an orthopedic spine surgeon...he could not have looked at your MRI and told you it might be a vitamin deficiency....You might have that too, but the reason you need to see a spine surgeon sooner rather than later is due to the cord compression and myelomalacia. I would suggest you look this up (myelomalacia) and familiarize yourself with the condition so you will be able to discuss it with the spine surgeon. It was probably caused by the whiplash injury many years ago....You want to look for either a fellowship-trained orthopedic spine surgeon or a neurosurgeon whose practice is limited to the neck and back.

    Unless your insurance carrier demands it, many spine surgeons see new patients without a referral. I would suggest you do some online research to check out the spine surgeons in your area. Ask your friends and acquaintances who comes highly recommended. You will want to find the surgeon with the best training and experience that is available to you. Most likely you will need surgery.

    I wish you all the best...and encourage you to see a spine surgeon as soon as you can. Do not put off finding one.

     
    Old 05-29-2013, 04:00 AM   #3
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    Re: Cervical MRI and surgery

    Sadly, the orthopedic surgeon I saw was, in fact, a spine specialist. I have looked up myelomalacia and it seems to be hard to find info on, though I understand it's fairly serious - I did discuss it with the neurologist yesterday and he said it is from current damage, not from my previous injury. I am not sure if maybe my ortho was trying not to scare me? I don't know - he was in and out and said I needed a neuro consult. I will not be having him operate on me.

    Anywho, I have an older friend who just had a laminoplasty and whose wife was a surgical nurse for years at a big teaching hospital and they highly recommended 2 neurosurgeons, so I am trying to get my GP to give me a referral because all of the specialist offices around here require a referral from the docs so they can review how soon you need to be seen.

     
    Old 05-29-2013, 01:45 PM   #4
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    Re: Cervical MRI and surgery

    Jessica, GP's seem to be 'on restraint' with a view to referrals. I also have spinal cord compression that has progressed since my original diagnosis nearly 10 years ago and my options (according to my GP) are to pay for a private consultation or to be referred to a 'conservative back pain clinic'. It's another attempt to keep orthopaedic waiting lists down. I have a lot of other serious health issues at the moment so have opted for the latter but, if I were you I would push your GP. I have managed to get an out of area referral to a well recognised specialist for another issue - with persistence. Be calm, collected, informed and very, very persistent - if need be put everything down in writing stating that you have taken this course because of the seriousness of your condition as advised by your neurologist....

     
    Old 06-15-2013, 09:42 AM   #5
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    Re: Cervical MRI and surgery

    kitti - thanks. I did end up getting in to see a second opinion - they want to do ACDF C3-C4 and C4-C5 - she doesn't want to do the C5-C6 level because of my age. I am finding it all very overwhelming to think about having neck surgery as I have a young child, can't get a job until I have recovered, and I guess just because it is a scary thing. I guess I am more afraid of having an accident and becoming paralyzed though - I am an avid equestrian and have been given a strict no riding from the neurosurgeon until after surgery, at which point she feels I will be ok to get back on.

    Anyway, I guess I am just getting frustrated that after 2 neuro consults my GP is still acting like this is no big deal even tough they now say I need surgery =/

     
    Old 06-15-2013, 10:47 AM   #6
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    Re: Cervical MRI and surgery

    I would suggest a third opinion. Reading your MRI, I am struck by how "mild" intrusions into the canal can "flatten" your spinal cord. If your spinal canal started out with healthy dimensions, that wouldn't happen. I suspect that you have developmental (or hereditary) spinal stenosis, which means that your canal developed to less than an optimal dimension. This would allow relatively minor intrusions to reach and impact the cord.

    The surgery to directly address your spinal canal stenosis is a laminoplasty, where the spinal cage is opened up (from behind) to increase the size of the canal. This allows the spinal cord to move backward, away from the intrusions impacting it from in front. You could have four levels (C3-6) done.

    I'd advise being careful about your choice of surgeons. Some just do ACDF's day in and day out, and so that's their solution to everything. Some of these surgeons don't even know how to do laminoplasties, as a laminoplasty is as different from an ACDF as baseball is from basketball.

    I can see why the doc could have thought that you have a systemic problem with your hands. Usually, cervical spinal problems do not affect both sides equally. It's certainly possible, though, I guess...

    Even if your hand tingling isn't coming from your cervical spine, that myelomalacia needs to be addressed. You can't cure it, but you need to do all you can to keep it from getting worse.

    If you want to read more on laminoplasties, you can read the thread I started called "Cervical Laminoplasty Chronicle"...

    Last edited by WebDozer; 06-15-2013 at 10:53 AM.

     
    Old 06-15-2013, 02:32 PM   #7
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    Re: Cervical MRI and surgery

    Thanks WebDozer - I was actually quite surprised when she suggested ACDF, but I didn't really think to ask why that and not laminoplasty. She did do a laminoplasty on the friend who referred me, so I suspect she has a reason for ACDF over laminoplasty. I do have congenital stenosis, and I do have what she called a "significantly" herniated disc and a bulging disc as well as the bone spurs - from what I have heard from the neurologist/neurosurgeon I suspect the stenosis is more significant than the radiologist read it. But they have also both said that they have seen tighter stenosis without myelomalacia and that with the neurological symptoms is why they feel they can't just watch it and I have to have surgery one way or the other. I would prefer a laminoplasty if it's an option - I do know that I have loss of loridosis in my neck and at one point was told I had mild kyphosis, but I am not sure if that is still true or if it was really true to begin with - my guess is that might be why she is suggesting ACDF over laminoplasty.

     
    Old 06-15-2013, 03:00 PM   #8
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    Re: Cervical MRI and surgery

    OK! I see you're way ahead of me. I can see why either kyphosis or herniation would be a contraindication for laminoplasty. The myelomalacia is a bit odd, given the still-minor nature of the cord impingements, and also given the seemingly mild symptoms.

    I think yours may be one of those cases where the surgeon(s) are seeing things the radiologist didn't mention, one of which is the herniation. Really bugs me when radiologists do a bad/indifferent job, but I guess they know they always have specialists who can/will look more carefully.

     
    Old 06-15-2013, 04:29 PM   #9
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    Re: Cervical MRI and surgery

    I figure I am just glad the radiologist mentioned the myelomalacia which got me to the specialists =P If that hadn't been there, I think that between my GP and ortho doc, I would have been sent home with yet another "all in my head" diagnosis. I guess I am glad they caught it before I injured myself again and ended up with some degree of paralysis =/

     
    Old 06-15-2013, 11:01 PM   #10
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    Re: Cervical MRI and surgery

    When did you have a whiplash?

     
    Old 06-16-2013, 04:23 AM   #11
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    Re: Cervical MRI and surgery

    10 years ago, nochange. And it was just a fall in a snowy parking lot where I turned to catch myself too fast. No vehicle accident or anything =/ The neurosurgeon says that the numerous falls I have had off horses over the years have probably contributed.

     
    Old 06-16-2013, 09:48 PM   #12
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    Re: Cervical MRI and surgery

    Perhaps it's better not to ride any horses. If your neurosurgeon says that, then riding horses is not good. Thanks for your input.

    By the way, a fall in the snow where you turned to catch yourself is not the same as whiplash done by car accidents. It cannot have the same impact.

    Even I, who had a severe whiplash, don't need to do a neck surgery.

    Last edited by nochange; 06-16-2013 at 09:50 PM.

     
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    Old 06-20-2013, 07:11 AM   #13
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    Re: Cervical MRI and surgery

    Nochange - I don't ride the same kind of horses now that I used to - it's pretty unlikely that I would go off, but my neurosurgeon has said that while she is not ok with me riding right now, she will be fine with it once I have surgery.

    As for the whiplash - it may not have been as severe as some cases of MVA, but I was entirely unable to move my neck for almost a month and in a soft collar for weeks. I ended up in ER because it was a worker's comp issue, and they made me go, and was diagnosed with neck sprain. I guess I would hate to know how bad it can be in a MVA =/

    Webdozer, I feel my symptoms are mild, but I do have several I had no idea were related (bladder issues, clumsiness, balance problems, loss of fine motor control, left arm and leg randomly falling asleep throughout the day, ice water sensations on my arms, muscle twitching) I have just been told for so long that they were nothing to worry about and/or in my head that I think I have just incorporated them as normal. I hope that some of them clear up, but the NS says that since they have been going on so long, many probably won't

     
    Old 07-20-2013, 01:50 PM   #14
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    Re: Cervical MRI and surgery

    Wanted to post an update since I now have 4 opinions and am really more on the fence about surgery than ever.

    So the first neurologist said my symptoms were certainly from my neck and that I definitely need surgery soon and that with the bruise on my spinal cord if I were to sustain a whiplash injury now I would likely be completely paralyzed - he also said that the discs in my neck in combination with the congenital stenosis is actively da,aging my spinal cord and if I don't have surgery I could wake up and be partially or fully paralyzed at some point, just from living. He had previously done an EMG on both arms to check for carpal tunnel that were all normal. I am not sure what the results of his neuro exam were, as they were done before the stenosis thing was even a blip on my radar, and I still believed that my parasthesias were caused by carpal tunnel, but I know he didn't do any hoffman's tests or Romberg test - I can't even remember if he did the normal strength/reflex tests.

    The first neurosurgeon said that she wanted to surgery sooner rather than later - they found left tricep weakness, left positive hoffmans, 3+ reflexes in arms and legs, very positive Romberg test. She gave me a window of "a few" months to have surgery, and said it wasn't an emergency but should be done. Nor horseback riding until after surgery. She offered me a 2 level ACDF for C3-C4 and C4-C5.

    The Orthopedic spine surgeon said I needed surgery at some point and that there wasn't any point in putting it off, though it wasn't an emergency. He did not do a neurological test as he is the one who sent me to the first neurologist. He offered me a laminectomy from C3-C6.

    Third Neurosurgeon (and the one who my GP apparently trusts the most) had a PA come in to do my neuro exam - she found nothing abnormal except brisk reflexes in both legs and my right elbow. She did not do a Romberg test. I noticed a couple of times that my strength seemed remarkably different from my left to my right, she did not seem to. The Neurosurgeon himself said that he felt that I was a surgical candidate. However, he also said that what I needed to do was to pick a disability level that I was not comfortable with keeping forever and then have surgery before that time, otherwise it was up to me when to have it. He said it's possible, though unlikely, that my symptoms won't get any worse. He said that either the ACDF (which he also suggested a 2 level saying that it would likely be anther 10-15 years before I needed another surgery for C5-C6 and they might have something better to offer me then) or the laminoplasty/laminectomy solution would be fine, though he would lean 55/45 in favor of the ACDF despite my congenital stenosis because I have loss of loridosis as well, but that I would probably have to get other docs involved if I had ACDF as I have severe vit D deficiency that is not responding to oral treatment which might make me more likely to have failure to fuse. He also said they would do a 2 level artificial disc and that they could try to get insurance to pay for it, but that we would have quite a fight to make it happen, if they would go for it at all. He also said he felt the risk of paralysis from injury was small and to keep riding my horse because it makes me happy.

    So, after this last doctor, I am left wondering if I need surgery at all, really, but also thought it was really strange that the PA didn't find any of the abnormalities that other docs have found. Before I saw the first neurologist, I was seeing a pain doc for my herniated lumbar disc - I had mentioned to her that the ortho spine doc thought it might be my neck and not carpal tunnel, she did a bunch of reflex testing and said I had a positive Hoffman's and brisk reflexes on my arms and legs (3+) I wonder if this made him more relaxed about the surgery option.

    I just don't know what to do - anyone have any insights that might help me make this decision? I can't tell if I am in denial of the severity of the issue or overinflating it.

     
    Old 07-20-2013, 05:41 PM   #15
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    Re: Cervical MRI and surgery

    I don't mind seeing that two docs recommend posterior decompressive surgery. Confirms my suspicion of hereditary spinal stenosis.

    While I wasn't happy with the job the radiologist did, I would note that he said the intrusions into your canal are "mild to moderate". One might infer from this that the decompression would address your problem more globally than disk removals.

    You could opt for a two-level laminoplasty at C3-5, with laminotomies at C2 and C6.

    The C3-5 two-level ACDF also seems like a perfectly good option.

    Or you could do the laminoplasty and maybe do the ACDF's later. You're young... you have a lot of years to squeeze in more surgeries...

    I'm not real optimistic about the neck pain, though. The whiplash is muscular, not spinal. At least that's my amateur's understanding...

     
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