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    Old 04-10-2014, 02:25 PM   #1
    ChuckStr
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    moderate stenosis - thoughts?

    I had problems with neck and shoulder pain (mild) and tingling in hands and feet about 6 years ago that largely subsided with PT over a couple of months. I've had the tingling off and on but Drs attributed that to anxiety.

    3 weeks ago, I started having severe left shoulder pain (9/10) and neck pain (5/10) which developed weakness in my right bicep (4/5) and hand (grip 50% of right). The pain seems to be reduced by oral steroids but they haven't affected the weakness that I can tell. I've also started to feel a "heaviness" in my legs (unsure if it's related), tingling in my feet, and tingling in my right hand.

    A synopsis of my current MRI is as follows : C3-C4 mild posterior bulge with mild facet and uncovertebral degeneration resulting in mild foraminal stenosis > on left, C4-C5 broad based posterior osteophyte resulting in mild-moderate canal stenosis (AP 10.3mm) with mild-moderate facet and uncovertebral degeneration resulting in moderate to marked foraminal stenosis > on left, C5-C6 broad based posterior osteophyte up to 5mm in height resulting in moderate canal stenosis (AP 9.1mm) uncovertebral and facet degeneration resulting in moderate to marked bilateral foraminal stenosis, C6-C7 broad based posterior osteophyte causes impression on thecal sac with no significant stenosis uncovertebral arthropathy causes moderate to severe right foraminal stenosis and mild left foraminal stenosis,

    The reading radiologist also indicates a diffuse patchy signal change in cord indicative of possible myelomalacia. Two other radiologists, my neurologist and spine specialist I've seen disagree with that.

    My spine specialist says don't worry it's nerve root impingement likely to go away but I'm not convinced it's not something to do with the central stenosis. I'm going to see more surgeons over the next week to get more opinions but wondering if there were any thoughts from folks here about what to ask, similar experiences etc. Thanks everyone, this is my first post!

     
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    Old 04-11-2014, 11:29 AM   #2
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    Re: moderate stenosis - thoughts?

    Welcome to the board. I usually hang out on the "back problems" board where we have more members with lumbar issues, but I saw your post and wanted to suggest that you look online for a dermatome map. This will show you which spinal nerves innervate which area of the body.

    Specifically take a look at the C6-C7 dermatomes and see if this matches where your pain is located. When you say shoulder, I don't know if you mean the back, like the shoulder blade or on the front side.

    The MRI is just one piece of the diagnostic puzzle, and the findings need to be correlated with what the spine specialist finds upon physical exam, basic neurologic exam and after listening to your description of symptoms and how they affect your life.

    You will note that at C6-C7 shows degenerative changes of the disc and the facet joints that are causing moderate to severe right foraminal stenosis and mild left foraminal stenosis. Radiologists use specific adjectives to describe how serious an issue is and they have meaning to all physicians. At least for the spine, they are: minimal, mild, moderate and severe. There isn't much room beyond severe for something to get worse...so it is very likely that these changes are pinching the nerve or nerves in the foramen (a foramina is an opening located at each vertebral level, on each side, through which spinal nerves exit the spine and go out to a specific area of the body). Your foraminal stenosis appears to be worse than stenosis in the central canal.

    I would want to know how the doctor thinks the stenosis is going to go away.
    Also find out if there is cord compression.

     
    Old 04-11-2014, 12:06 PM   #3
    Tim025
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    Cool Re: moderate stenosis - thoughts?

    ChuckStr, your mri reports sound similar to what mine were back in 2007.
    My one and only real issue though was a constant burning on the backs of my hands, primarily on my left hand. Although I was advised by a neurosurgeon to have either a laminectomy/fusion at the time, a neurologist felt that I would be smarter to treat the symptoms with Lyrica and exercises which I have been on ever since. Two years ago the pain began to worsen so I had another mri which showed that the narrowing of my spinal canal c-3/c-7 had worsened slightly so I tried every "natural" form of therapy available with little success.
    On Oct. 1 2013 a new mri showed almost a complete lack of spinal fluid at the c-3/c-7 area because of severe compression on the spinal cord. On Oct.25 2013 I had a radical posterior laminectomy c-3/c-7 WITHOUT any instrumentation.
    During the healing process I have experienced many weird sensations, electrical "buzzing" in legs and arms and muscle weakness and twitching at different times. However at almost 6 months out all of those issues have cleared up and I have been cleared to golf again and hopefully play softball soon ( I am 58 years old ).
    The latest mri showed complete decompression of the spinal cord with some damage that MAY be permanent consequently my hand pain still exists although lessened somewhat and hopefully will continue to improve.
    I don't know if any of this helps but if I had it to do over again I would probably have had some type of procedure done sooner in the hopes of preventing any permanent cord damage.
    Good luck and look at your mri's closely yourself and listen to your body.
    Tim

     
    Old 04-11-2014, 12:44 PM   #4
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    Re: moderate stenosis - thoughts?

    Thanks for the replies Teteri and Tim. It helps to know there are others out there. I'd looked at the dermatome map and it appears there is stuff with C5 and C6 at least (weakness in bicep c5, largest pain at back of shoulder top of arm joint area (c6)). Tingling is in whole hand, both sides though so not sure there. Tingling in feet and that they think may be due to uninvestigated lumbar issues. Yay.

    As near as I (and all of Dr readers of my MRI) can tell there is no cord compression. At the worst level (c5/c6) I still have about 2mm of space on one side of the cord although the osteophyte is touching the cord on one side (no visible fluid there). That was what I was most concerned about, was getting whacked there and being paralyzed but neither of the folks I've gone to seem too concerned.

    I have no idea how they figure the stenosis will go away and as a matter of fact both said it would not. I think the idea is that a great deal of the impingement is due to swelling in the area and not the stenosis itself and if the swelling goes then the nerves may be decompressed.

    Tim, it sounds like you were able to put off surgery for 6 years which I would do if I knew the weakness wouldn't stay. I think a lot of my pain is being hidden by the oral steroids I',m taking, and I guess I'll find out since I'm due to go off them. I've a couple more consults and we'll see what everyone says.

    Thanks again for sharing.

     
    Old 04-14-2014, 09:01 PM   #5
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    Re: moderate stenosis - thoughts?

    I've now had 2 opinions and am waiting for 2 more. First guy, wait on surgery, try pt etc. His focus is symptoms and he thinks mine are due to radiculopathy which he thinks is partly due to inflammation which he thinks will go down. The second guy believes there is evidence of cord compression and that I should have surgery sooner rather than later. He was looking at the t2w axial images and it sure looks like there is no fluid around the cord but I'm not 100% convinced that there is compression. He suggests 3 level acdf with cage and fusion. I don't know if that's overkill or not. I guess I'll wait for the final two consults.

    In the meantime, I've been having some lower back pain, leg heaviness and bowel/bladder symptoms (not sure if related) as well. I looked online, was wondering how many folks with osteoarthritis of the neck also have it in the lower back? What a mess at 47.

    Thanks for having a place where I can vent a bit. I'll post more when I get more info, but I wonder if anyone has started a list of good questions to ask about surgery. Things like "will I need to wear a collar?" etc. I looked but didn't see one.

     
    Old 04-14-2014, 09:18 PM   #6
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    Re: moderate stenosis - thoughts?

    You are very much in the same boat as me, and I'm 14 days away from a cervical laminectomy of C4 to C6 with posterior fusion.

    That heaviness in your legs is not radiculopathy. That is classic cord compression symptoms. Most of the rest of your symptoms sound like nerve root compression, especially if it only affects one arm and not the other, but you might be like me - you have both.

    Have you had your reflexes tested? Did you have an 3+/4 or 4/4 results in your leg reflexes? That is another sign of myelopathy, not radiculopathy.

    My AP diameter is 6.8 mm. My spinal cord is compressed flat, but I do not have any bright spots on the T-2 MRI results, so no evidence of permanent damage.

    I can tell you this. When I had my first MRI 2 years ago, they said it was all moderate, because I didn't have any symptoms other than neck pain. I can read MRIs and they haven't changed in 2 years, but now the save MRI is interpreted as severe, and the only difference I can point to is the change in symptoms.

    I have a Hoffman's sign, a Spurling's sign, and Lhmerrites signs. I've had the clumsy hand come and go (couldn't get my keys in the car), and I have all kinds of wierd sensations walking. Sometimes it feels like I'm walking in quicksand, one day I felt like I was walking on springs, where my foot would go through the concrete then bounce up and down, then today it felt like I was walking downstairs when I was walking on pavement.

    When you say tingling, have you ever had the sensation that lighting was running from your neck to your fingers, sort of like in Star Wars when the Emperor was electrocuting Luke Skywalker?

    I ended up seeing 11 different doctors, including 3 neurosurgeons and 3 orthopedic spine surgeons. 3 of the spine surgeons were professors at large medical schools, and all 3 were directors of spine surgery. I had so many different surgeries and opinions I nearly went nuts trying to figure out who was right. In the end, I went with a highly recommended neurosurgeon who wanted to do a middle of the road surgery on me. But along the way, I ran into a lot of doctors who told me to try stronger narcotics (like massive doses of oxycodone). There are no guarantees with complex spine surgery, so be prepared for those who resist. The key is to ask why each time. Why operate, why not operate? Why this surgery and not that surgery? etc.

    The only conservative thing that helped me was oral steroids, and then only at high doses (the first 2-3 days of a taper). I tried facet blocks, medial branch blocks, an epidural steroid injection, and lots of physical therapy, over the course of 2 years.

    Last edited by jeff557; 04-14-2014 at 09:27 PM.

     
    Old 04-14-2014, 09:51 PM   #7
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    Re: moderate stenosis - thoughts?

    Thanks for the reply Jeff. Why did your surgeon go for the laminectomy as opposed to an anterior approach if you don't mind me asking? All the reflexes in my legs are normal so far. Left arm is 1+. In fact the pain in my neck and arm has reduced a fair amount, although I do have just tingling in my right hand no significant pain.

    6.8mm is pretty small. I'm at 9.1mm at c5-c6. I've never had lhermites or any electric feeling really. More like pins and needles I guess. A nearly identical MRI from a year ago was read as at least moderate stenosis, where my latest one was read as mild to moderate. I think tour right that symptoms make a difference and also more than expected reader bias.

    Oral steroids helped me as well, and overall the pain has gone down although the weakness has not.

    I hear what your saying with the multiple opinions. 2 of the 4 people I have lined up are professors at a prestigious medical school. Asking why is good advice. I haven't heard great answers from either of the surgeons so far but I'm getting better at asking questions. It sounds like you were able to get a good answer for yourself. Thanks for the help and encouragement to do the same.

     
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    Old 04-14-2014, 09:59 PM   #8
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    Re: moderate stenosis - thoughts?

    Make them show you as well. One of the surgeons I saw had a viewing room where he had 8 different giant screen HDTVs for viewing my MRI and CT scans. Looked like the bridge of the Star Ship Enterprise. Have them show you what they are talking about, on the MRI, CT scan, x-ray, etc.

    I'm going with the laminectomy because most of my cord compression is coming from the back side. Out of the 6 different surgeons I saw, only one said I could get away with an ACDF. 3 said I needed both an ACDF and posterior fusion, so front and back or what they cal 360 (degrees) surgery, and 2 said laminectomy and posterior fusion (back only surgery). The surgeon I chose is a professor and director of neurosurgery at a leading medical school, he has both a MD and neurosurgery training (and is director of neurosurgery) and also has a master's degree in spinal biomechanics. He actually designs the hardware he uses in surgery.

    Last edited by jeff557; 04-14-2014 at 10:00 PM.

     
    Old 05-20-2014, 02:58 PM   #9
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    Re: moderate stenosis - thoughts?

    Well, I'm back. I ended up seeing 4 spine surgeons and a couple of neuros as well for good measure. The pain has now largely subsided due to steroids, therapy and therapist traction and has been gone now for several weeks. I still get a shot of numbness down my arm once in a while, but the main issue is the weakness mostly felt in wrist extensors (grip), pronator teres (dumping stuff out of a pan) and biceps to a lesser degree.

    Reflexes have returned largely to normal everywhere but I've started getting fasciculations (little muscle jumps) in my legs as well as the heaviness. None of my Drs seem particularly worried and believe this is all unrelated and benign(as my lumbar spine looks surprisingly good). One neuro did an EMG which showed heavy signs of an acute C6 radiculopathy without other pathology but suggested that the nerve damage in my left arm may be significant. It seems as if my strength has come back just a tiny bit (or maybe wishful thinking). They say this is all normal for 2 months, but has anyone else experienced resolved radicular pain etc but remaining weakness, due to bone spurs impinging on nerve roots? The consensus (although not unanimous) has been to stay away from surgery if possible as long as outcomes remain "good".

     
    Old 05-21-2014, 03:24 PM   #10
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    Re: moderate stenosis - thoughts?

    Fasciculations aren't really a concern. I was told that they were due to nerves being "****** off" which I think means irritated. Also, like you, not one of the spine surgeons I saw mentioned these muscle twitches as being a concern. But, after surgery, my muscle twitches went from almost constant prior to surgery, to less than 1-2 times a day immediately post op, and are now completely gone. I think these are more a barometer of what is happening, because there are a lot of benign conditions that cause twitches, and there is really no harm in them by themselves.

    I'd say yes it is normal to get varying type of improvements from the conservative measures you describe. However, the real concern in what you describe as continued problems are the weaknesses in your arm that correlates exactly with the EMG findings of a C6 radiculopathy, and the heaviness in your legs is a very concerning sign of spinal cord compression. The nerve roots in your legs are down in the lumbar region, so unless you have compression in that region, the heaviness has to be coming from spinal cord compression in your neck.

    I'll also tell you that of all the things you describe, pain from a surgical standpoint is the least relevant. The fact that pain has cleared up with some of the conservative measures might feel good to you and even lead you to think you won't need surgery, but pain isn't why surgeons operate. The primary reason for that is that insurance companies won't pay for spinal surgery to stop the pain because the efficacy is rather poor, so when the treatment is expensive and the outcome is 50/50, insurance companies won't pay for you to have surgery. But you have things much more serious going on than pain.

    The strength can really be hard to measure and quantify. The reason is that due to the nerve root compression, the muscles can become spastic, and produce unnatural strength sort of like getting extra voltage from your nerves that control the muscle. So this is some type of artificial compensation happening, that will come and go as you are experiencing.

    I was at the end of my tour of doctors when I was told frankly that the loss in strength in my arm might be irreversible, and the difficulty walking that I began having from the "heaviness" in my legs might also be irreversible, and that the longer I went without having surgery to correct those problems, the higher the probability became that they were in fact irreversible. That is why doctors are supposed to move you to surgery sooner than later. If you look at the data on myelopathy, the outcome of surgery is best in patients who have had symptoms less than 1 year prior to surgery.

    Last edited by jeff557; 05-21-2014 at 03:30 PM.

     
    Old 05-21-2014, 07:40 PM   #11
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    Re: moderate stenosis - thoughts?

    Thanks for your response Jeff, and the private mail. It sounds like you have a unique case there.
    The interesting thing is that none of the drs really believe I have any normal signs of myelopathy although one does think the leg symptoms are related. There is no hand wasting or weakness and no UMN signs at all (including spasticity or proprioception loss) I'm going to my neuro every couple of weeks and my pt is monitoring all this closely as well. The MRI doesn't show signs of compression to the level that should be causing symptoms (its more of the slightly moving the cord variety). The hope is that I can stabilize all this enough with exercise etc that I can put off surgery for potentially a long time although most believe I'll need it at some point. In the meantime, I'm trying to lose weight any get healthy so that the surgery works better if I need it and maybe that will help remove some of the pressure from my spine and help remove the need for surgery. I was trying to get an idea if the weakness may still go away as the plan is to watch carefully for another 1-2 months and then evaluate unless something more urgent appears. Most drs believe the strength will come back and it sounds like there are some folks for whom that happens. Thanks again.

     
    Old 05-22-2014, 01:55 PM   #12
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    Re: moderate stenosis - thoughts?

    BTW, I presented all of the above from the consensus of my Drs opinions. For myself, I'm definitely still on the fence. I really don't want the surgery because I think it is a slippery slope and may not do me any good. On the other hand I don't want permanent deficits. Most drs think the leg stuff is unrelated because there isn't really anything clinically measurable. No weakness, no spasticity, no cramps, no gait or balance issues. It sort of comes down to am I suffering a c6 radic with some extra unexplained as yet mild symptoms, or am I suffering myelopathy. I'm with Jeff that if those symptoms are related (myelopathy) than I should probably have the surgery. I know that my lumbar spine is marginally clear as I had an MRI of that as well, but the symptoms are subtle enough that they could be from anxiety brought on by all of these health issues or from the slight pinching happening in my low spine. Although, there are no guarantees everyone I talked to and most studies I've read say waiting a (short) while to see how things go in the state I'm in should be safe enough. I hope they are right.

    Interestingly, I went to all of the surgeons while I still had significant pain and every one of them said, oh yeah, the pain will be gone after the surgery. One guy even said, I really don't recommend surgery for you now (in the state I have with no pain), since I will probably give you pain and may or may not help your weakness. I guess they are coming at it from the radic side where there is more evidence that the pain can be eliminated, although even the one surgeon who thought I may have early myelopathic symptoms mentioned that there was a 90%+ chance the pain would improve.

     
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