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Cervical spine issues - confused


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Old 08-27-2013, 07:09 AM   #1
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Cervical spine issues - confused

Hi,

I am new to the boards, but have been a long time reader. Please excuse me if this runs long - it's been a long 7 years. I'm 31 and outside of my spine I am pretty healthy (before my spine issues I was very healthy).

Played rugby for several years as a young’un, was a firefighter for 5 years and then was t-boned by a guy running a red light. Doctors sent me to PT, took X-rays, dismissed my pain for almost 3 years before someone listened and I got an MRI (2009) stenosis with 7mm herniation. I was advised to see a spine rehabilitator and pain manager (he is an excellent doctor). I was told I would eventually need surgery. In an attempt to put off surgery (or even prevent it) I underwent PT, acupuncture, massage TENS, ultrasound, chiropractic, decompression traction, pain meds, muscle relaxers etc.

In my latest MRI it showed disc herniation and bone spurs c-3 thru c-6. Severe spinal stenosis. Central canal narrowing and cord flattening. Moderate to severe foraminal narrowing. Arthritis, Straightening of the lordosis.

Luckily I do not have any cord signal issues. I underwent to EMG's which came back ok. I have good range of motion. I sometimes have numbness in my pinky and ring fingers. My main complaint is Neck and shoulder pain. I also have bad jaw pain. Although I have started to develop a strange weak ache in the top of my arms. I've been working with a c-2 only chiropractor and put the new pain from that. I realize there are a lot of ppl who have it worse – and to those people I am in awe you fight through each day.

My spine doc said his concern is I have no room in my spine and any trauma could be devastating. So off to an ortho surgeon I went. He looked at the MRI, conducted an exam and found that my patella reflexes are hyper active. He recommended I have a posterior Laminectomy from c-3 to c-7 with fusion.

I went for a second opinion - the neurosurgeon said to wait, monitor myopathy and do anterior foraminal surgery if anything.

So I went for a third opinion (ortho surgeon) - he also said wait, but to do some injections and if they don't work consider doing ADCF. I asked about a Laminectomy and he said it would only help arm pain, not neck pain.

I went back to my Spine rehab guy who said we can do injections, but not sure if they would be worthwhile and if they are they would only be temporary - will need surgery.

So now I have three different opinions and not sure what to do. I realize I can't ask for your guy's opinions but maybe you have some experiences that may offer some insight into what I can expect or what worked and what didn't. Really any help would be great; I'm just confused about what to do.

Do most people be proactive and have surgery to prevent further issues, or wait until they show some spinal cord signal problems? and in that case is it too late?

I'm pretty terrified about surgery, but I have a baby boy, a loving wife and want to be able to be the most worthwhile father/husband.

Sorry it's so long - half vent half seeking answers. If you have read this far I commend your stamina and attention span.

Thanks

 
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Old 08-27-2013, 01:09 PM   #2
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Re: Cervical spine issues - confused

First... surgery is AN option, not the LAST option. That kind of thinking should have gone out with the 1970's, but it still hangs on.

I commend you for getting three opinions. I guess since the first opinion seemed so drastic, you kind of had to, though.

The recommendation of a laminectomy is interesting. It would seem that the surgeon thinks that you not only have intrusions coming from the front of the spinal canal, but that your canal was too narrow to start out with.

Also interesting is that one surgeon recommended extensive surgery, while two others recommended waiting.

If you are interested, you can transpose the level-by-level part of your radiologist's report and get informed-nonprofessional explanations here as to what it all means, how it relates to your symptoms, and what might be done.

 
Old 08-27-2013, 02:01 PM   #3
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Re: Cervical spine issues - confused

Thanks for your reply. For me I feel the need(ed) to extinguish all other non-invasive treatments before going under the knife. And in my mind I have tried almost everything and I am closing in on decision time.

This MRI was performed in 2012. I had one done the other day. I have yet to receive the report but my doctor did. He did say that it has deteriorated a little more.

Any thoughts on the MRI would be great.


MRI -

Technique 1.5 Tesla MRI was utilized. Sagittal T1, STIR, and T2- weighted images were performed through the cervical spine.


FINDINGS: Vertebral bodies are normal in height. There is no evidence of spondylolisthesis. There is straightening of the normal cervical lordosis. No evidence of vertebral fracture. No evidence of destructive bony lesion. The visualized portion of the posterior fossa is unremarkable without evidence of Chiari I. The visualized spinal cord is normal in signal. Facet joints appear unremarkable throughout the cervical spine except C7-T1.


C2-C3: Normal

C3-C4: Mild disc desiccation with normal disc height. There is a diffuse disc bulge with left greater than the right unconvertebral osteophytes and left posterior endplate osteophytes. AP diameter of the thecal sac measures 8.5mm in the midline with mild left ventral cord flattening. There is mild left foraminal narrowing. No right foraminal stenosis.

C4-C5: Mild disc desiccation with normal disc height. There is a diffuse disc bulge with superimposed central disc protrusion. There is additional left foraminal disc protrusion. AP diameter of the thecal sac measured 8mm in the midline with mild left ventral cord flattening. There is moderate left foraminal narrowing. No right foraminal stenosis.

C5-C6: Mild disc desiccation with normal disc height. There is a diffuse disc bulge with superimposed central disc protrusion. There is additional left foraminal disc protrusion. AP diameter of the thecal sac measured 8mm in the midline with left greater than right ventral cord flattening. There is severe right and moderate left foraminal narrowing.

C6-C7: Mild disc desiccation with normal disc height. There is a diffuse disc bulge. AP diameter of the thecal sac measured 8.5mm in the midline with mild ventral cord flattening. There is mild to moderate right and mild left foraminal narrowing.

C7-T1: Normal disc signal and height. minimal disc bulge. Moderate right and mild left facet arthropathy. No stenosis.

T1-T2: Normal

IMPRESSION:

1. there are disc bulges/osteophytes and protrusions at C3-4 through C6-7. This results in Mild C3-4 and C6-7 and mild to moderate c4-5 and c5-6 central canal narrowing with cord flattening.

2. There is mild left C3-4, moderate left c4-5, severe right and moderate left c5-6, and mild to moderate right and mild left c6-7 foraminal narrowing.

3. there is facet arthropathy at C7-T1.

4. Straightening of the normal cervical lordosis.

 
Old 08-27-2013, 03:45 PM   #4
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Re: Cervical spine issues - confused

OK, to start with the adjectives:

Moderate = clearly there, and possibly borderline problematic

Severe = likely problematic

straightening of the normal cervical lordosis = your cervical spine reverses the forward lean of the thoracic spine at shoulder level - this change to (relatively) backward-bending is called lordosis. The radiologist is saying you're not as lordotic as you "ought" to be. However, this is so common that it's almost boilerplate, at least for people who are 45+. For you, it MAY be a little worrisome, but I really don't know. Besides, he did not indicate that he thought it's problematic.

Mild disc desiccation with normal disc height. = your disks are starting to dry out, but haven't compressed yet. As you get older, they will compress, if you don't take care of them by stretching and by avoiding bad posture.

superimposed central disc protrusion = My guess is that he's saying the disk is herniated, that the soft inner filling has broken through the tough outer layer. I'm not sure that's what he means, but since he uses "protrusion" in ADDITION to "bulge", that's what I'd guess. If the disks are only slightly dessicated and still of normal height, but they're STILL herniating, then perhaps that's due more to trauma than to decades of wear and tear.

unconvertebral osteophytes and left posterior endplate osteophytes = Extra bone ("spurs") is being laid on to the interfaces between the disks and the vertebrae

AP diameter of the thecal sac measured 8mm in the midline = The spinal canal, measured down the middle from front to back is 8mm. This is narrow, but not terribly so. I've seen 4mm several times.

with mild left ventral cord flattening = Whatever is pressing back into the spinal canal (disk bulge + protrusion) is pressing on the spinal cord a little and flattening the front of it. Not "indenting", which would be the next step, but just flattening.

There is mild left foraminal narrowing = the foramina - the holes in the front/side of the spinal cage through which pass the nerves as they go from the cord down into your arms - are being narrowed by the disk bulges, and possibly also by the osteophytes.

Believe it or not, only one thing definitely looks bad here, which is the right foraminal narrowing at C5-6. If the foramen is narrowed enough, the nerve will be pinched (radiculopathy), which could cause neck pain, but also a variety of symptoms from your right shoulder down to your thumb... everywhere the C6 nerve goes.

It's a little odd that if you had a 7mm herniation in 2009, as the radiologist in 2012 only refers to "superimposed disk protrusions".

I'd be interested to see the report from the most recent MRI. I suspect things are noticeably worse, particularly at C7-T1, as the C8 nerve that leaves from that level goes to your pinky and ring fingers.

I don't see anything in your report that would correlate to jaw pain. As for the hyperactive patellar reflexes, that could be an indication of cord damage. (I still have hyperative patellar reflex from damage that occurred seventeen years ago.) That's a little strange, in your case, because the report doesn't seem to indicate enough pressure on the cord to cause damage. Maybe the latest one does...

Last edited by WebDozer; 08-27-2013 at 03:48 PM.

 
Old 08-27-2013, 04:05 PM   #5
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Re: Cervical spine issues - confused

Hi Lionor, Jaw pain especially intermittent radiating can be a sign of angina, meaning that the coronary arteries that supply the heart muscle with oxygenated blood could have an obstruction from plaque caused by high cholesterol, high triglycerides or sometimes the coronary arteries spasm. It might occur more frequently with strenuous activity but if i were you & it persists i would see my pcp or cardiologist for evaluation.

 
Old 08-28-2013, 06:31 AM   #6
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Re: Cervical spine issues - confused

WebDozer, Thanks for taking the time to write such a thorough message. One of the neurosurgeons did say the foraminal surgery would be the best/first option - so spot on there.
Gmak, thanks for your note. I will keep that in mind. I had a full work-up done recently and all my blood, liver, heart etc. levels were almost perfect. I can feel in my jaw that the muscle itself is always on, always in spasm. I grind/clench my teeth a lot - maybe from the pain?
Still unsure on what the next step is - I guess be conservative, try injections and see.
Can ADCF surgery remove bone spurs to allow for more room?
So my decision has a lot to do with pain, but also has to do with the best course to remain active. I want to decrease my risk of being susceptible to spinal cord injury. I am the "bread winner" in the family and need to continue to be as such. Will laminectomy make me safer?
I realize I am asking specific questions - I understand that fellow members will not be offering medical advise, but just some thoughts for me to mull around.
Thanks again guys – this is all very helpful.

 
Old 08-28-2013, 03:34 PM   #7
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Re: Cervical spine issues - confused

Dear lionor, You are exactly right imho to try to avoid any invasive to the spinal cord or spine period procedures until the dr has exhausted all other treatment options that are non invasive like PT, heat or ice, prescription anti inflammatory patches & topical gels, numbing patches, or medications like anti inflammatories, muscle relaxers, massage, ultrasound, TENS unit etc.

 
Old 08-28-2013, 04:09 PM   #8
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Re: Cervical spine issues - confused

Perhaps what the surgeon suggested was a foraminotomy? As the name indicates, that's a surgery to clear a foramen by cutting out obstructions. It is one of the three surgeries I have had. Started out to be a one-night stay but turned into an outpatient procedure. Very little pain or recovery time needed. It should be a minimally invasive procedure and could be described as microsurgery.

In my case, the problem was with facet hypertrophy, which is coming from behind the foramen. The posterior approach of the foraminotomy is ideal for that. In your case, the foraminal obstruction is likely coming from in front, and may be herniated disk material. I can't answer whether a foraminotomy would deal effectively with that, but I'd be very interested to know what the surgeon says.

As for exhausting every non-surgical option... that's fine, but do it quickly. Too many people go years trying to avoid surgery, which only allows temporary nerve effects to become permanent and irreparable damage. Unfortunately, for every non-surgical option, there are doctors, therapists, etc, who will want to maximize their profit from you, and will keep you on the string if they can.

 
Old 08-28-2013, 06:26 PM   #9
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Re: Cervical spine issues - confused

Lionor, I can relate to you on many points of your original post as I too am considering surgery not so much for the pain, but due to some weakness in my hands and feet. According to the doctor, numbness, tingling and weakness are early signs of nerve damage. My doctor also gave me a similar speech that a minor car accident or wrong fall could paralyze me. My current pain is actually minor with some radiating pain from the neck/shoulder blade area down to my elbow area. I've been doing electro-acupuncture with good results in dealing with pain.

I too am terrified about surgery because there could be complications, it is never 100 percent, there is a chance that the procedure can lead to degenerative issues at other disc levels at a later time, and once you do it you can never go back. I'm not sure how common this is, but I have heard that over several months or years, an untreated herniated disc can retract by resorption and form scar tissue. Some doctors call this healing, but there is still the risk factor of nerve damage that could happen at any time through this unknown healing duration. The risk and time of toughing it out may not be worth it especially if the pain is severe.

Obviously you also have to consider the flip-side as there are people with fantastic results after surgery. As mentioned by WebDozer, the last thing we want to do is to put it off until there is nerve damage that cannot be reversed.

I am new to this board and reflecting my thoughts from consulting with doctors on my own condition. I feel your anxiety and concern and agree that you should get a few more opinions to try and get a consensus. Have you already seen a neurosurgeon?

Last edited by Geespec; 08-28-2013 at 06:27 PM.

 
Old 08-28-2013, 06:56 PM   #10
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Re: Cervical spine issues - confused

Hi Lionor, Numbness, tingling, weakness indicate nerve compression that may become permanent & surgery which i had 4 lumbar laminectomies & did not know this, is predominantly to relieve nerve compression not to relief pain. I understood that you had intermittent numbness os pinkie & ring finger which certainly in my opinion would not indicate to me that i needed back surgery because herniated disc can get well on their own sometimes with time, however if the MRI shows severe nerve compression at foramen then i would see the best spine only neurosurgeon at a major teaching hospital for an opinion & then a spine only orthopedic surgeon. The drs that youve seen are their practices limited to doing spine only? I.e. the NS wouldnt do brain surgeries too & the orthos wouldnt do knee replacements too, just spine surgery only?

 
Old 08-29-2013, 12:44 AM   #11
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Re: Cervical spine issues - confused

Quote:
Originally Posted by Geespec View Post
My doctor also gave me a similar speech that a minor car accident or wrong fall could paralyze me.
Does your doctor know ONE person who has been paralyzed?

Last edited by nochange; 08-30-2013 at 03:34 AM.

 
Old 08-29-2013, 07:49 AM   #12
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Re: Cervical spine issues - confused

No kidding.... seems like maybe half of them say that. I guess the operative word is "could"....

 
Old 08-30-2013, 03:59 AM   #13
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Re: Cervical spine issues - confused

That always interests me. If you had a whiplash, howcome you don't suffer from neck pain but you have herniated disks? So then, you were not hurt that badly and so, your muscles, tendons and ligaments were not damaged, otherwise, you will suffer from severe pain ie chronic neck pain.

It goes like that: Whiplash first damages tendons,ligaments and muscles and then you have muscular pain ----- the thing is that you don't suffer from neck pain at all, and so, everything your MRI shows was not caused by the car accident.
(muslces first get tight in order to protect the bones, nothing happened to you, the accident was not that bad).

You didn't have a severe whiplash.
It is all genetic.

By the way, rugby can cause neck problems also. So here you go.

 
Old 09-17-2013, 08:06 AM   #14
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Re: Cervical spine issues - confused

I was waiting to re-post until I saw the neurosurgeon. I appreciate you taking the time to reply. I will try and respond in turn:

NoChange - I was trying to state my condition in as clinical a way as I could. I don't think I said I don't have pain, quite the opposite I have pain - neck and shoulder pain, everyday. Pain and not wanting to have inoperable nerve damage are the driving forces behind considering surgery. Doctors are focused on my spine - but I have muscle spasms, old scar tissue from tears and my muscles are forever "on". I'm told it's a) posture and b) trying to protect my spine. Posture is a catch 22 - I lean forward as my body tried to make a tiny bit more space in my spine - but that causing all sorts of posture issues. I agree that it's likely genetic to a large degree - the car accident was either a catalyst or just an alert of the start of something to come.

GMAK - thanks for the reply - How did you respond to the laminectomies? That's what the neurosurgeon said- that kind of surgery is no about fixing pain but about relieving compression. In fact the pain may increase afterwards given the trauma to the muscles. The Othros and the neuros are all spine specific and "top" rated surgeons in my area (one in the nation).

GEESPEC- Thanks for your reply and opening up about the similarities. I did speak with the Neurosurgeon last week. I have talked to four different surgeons and have received four different treatment opinions. The Neuro said wait and see. Said the laminectomy (since my primary issue is neck pain) would not be a great option. A common theme is surgery currently being elective and not required - and it's a grey area in that I may have to wait until I show "signs" of further compression, but then will the nerve damage at that point be reversed? I can't seem to get a straight answer.

WEBDOZER- A surgeon had mentioned a foraminotomy - some surgeons seems concerned with that whilst other don't. I have received three definitive opinions - Laminectomy from C2-C6, Discectomy on 2 or more levels (to include C5-6) and no surgery right now - wait and see.

I have seen time again therapists/chiropractors etc.. who say they can fix me, when in the end I just spend lots of money, take so much time out of my life and have no real improvement. My primary spine doctor said recently - you can try all different avenues to try and reduce your pain/symptoms - but at the end of the day only surgery can remove the bone spurs and stenosis. Do you know if a discectomy allows the surgeon to remove the bone spurs as well? or just the disc?

Thanks again guys - unfortunately after multiple doctors opinions I still have cervical issues and I'm still confused

 
Old 09-17-2013, 08:24 AM   #15
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Re: Cervical spine issues - confused

I can see why a surgeon would recommend decompressive surgery, but not why he'd want to do C2. C3-C6 seems to make more sense, based on your MRI.

Some things to consider about decompressive surgeries:

- There's another kind, called a laminoplasty, which I have had. This may require a more skillful surgeon, or at least a younger one. I've had a laminoplasty for C4-C6. You can read about it on the thread Cervical Laminoplasty Chronicle.

- It is not necessary to remove a lamina (laminectomy) or bend it backward (laminoplasty) to open up the spinal canal. A lesser expansion can be achieved by a laminotomy, whereby the inside of the lamina is shaved off, but the lamina itself is left in place. When I had a laminoplasty at C4-6, I also had a laminotomy at C3.

- Decompressive surgeries can access the foramina. If you have a multilevel laminectomy or laminoplasty, you can at the same time have foraminotomies done on both sides at the same levels.

As far as a choice between diskectomy and decompression, I would think it's a matter of where the "real" problem is. Is the problem that you have bulging disks, or is it more that you've got a too-narrow spinal canal and even smallish disk bulges can cause disproportionate narrowing of the canal? Clearly, you need multiple opinions, best obtained from surgeons who themselves have experience with both approaches.

Last edited by WebDozer; 09-17-2013 at 08:26 AM.

 
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