QuestionQUESTION: I was injured in a fall on ice.I've had a C4-5 fusion in 01 with outstanding results.I was back to work.Since this fall I've had ongoing pain(sometimes severe)with headaches and vomiting.MRI shows I have moderate multi-segmental spinal stenosis between C3-4 and C6-7.The subarachnoid space surrounding the cord is severely effaced but not completely obliterated and the cord is visibly contricted in this segment.Annular bulging and small posterior contour bulge at C3-4.Severe bilateral foraminal stenosis at C3-4.Significantly narrowed foramen at C5-6 on left side caused by disco-osteophyte.Moderate-sized left paracentral disc protrusion superimposed upon mild annular bulging and the protrusion is causing an asymmetric left-sided indention extrinsically on the cord.Second MRI taken states that protrusions are more prominent and there is definite cord compression.I have weakness,numbness,tingling in left are and a little in right arm.Symptoms are progressively getting worse.I am on 60mg oxycontin 3 times daily and 300mg lyrica daily which certainly help with the discomfort.I am just concerned of long term use of medication.Neurologist says that there will be no surgery,but at the same time neurologist states that I will require surgery on neck in future.I was hoping that I would have surgery sooner for some quality of life.I have been extremely frustrated at the lack of concern for ones quality of life.I also have severe headaches with vomiting.Friends and family have asked my wife if I was drinking at times because of the way I walk at times.I just would like to know if I will get worse and why I am not considered for surgery.The neurologist stated that even with surgery I will never get my strength back in my legs or arms because this is permanent.How bad will things get without surgery.Neurologist also said that heaven forbid that I fall again.I do not understand why that was said.Please give me some answers if you can.It would be greatly appreciated.
Sincerely
Robert
ANSWER: Although I am not a neurologist or medical doctor, it sounds as though the problem is related to the spinal stenosis in your neck. The spinal stenosis is a narrowing of the central area of the vertebra through which the spinal cord extends. The narrowing damages the nerves and causes symptoms such as loss of leg strength and decreased feeling in the feet and legs.
The damage is progressive as the stenosis continues to degenerate the vertebra and more pressure is applied to the spinal cord. That's why the neurologist said you'll need surgery at some time in the future. A procedure called a decompression laminectomy would be done to remove the back side of each vertebra that's involved and thereby relieving the pressure on the spinal cord. Because of your fusion, there may be some reason that the surgery cannot be done at this time.
Having said all that, I would recommend asking your doctor about the possibility of surgery in your specific case and why it isn't being considered at present. The neurologist is correct in saying that the damaged area will not return to 100%. As the stenosis progresses, so does the damage. If you're already having problems walking and your doctor is concerned that a fall might cause further damage, I would push a little harder to get the answers that you need. If necessary, seek a second or third opinion.
Thank you for your question, Robert. I hope that my answer was helpful.
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QUESTION: Dear Dr.Ryan
With all the problems I have,how bad or progressive will this situation get?Is the cord flattening considered a spinal cord injury?Would my headaches be coming from my neck injury?After my fall is when all these problems started because before I had no problems at all,and on no medication whatsoever.How would this medication affect me in the long term?Do you think that this fall I had would of caused all these problems?
ANSWER: The progression will be slow but steady. The weakness in the legs will get worse and then there will be upper body weakness or numbness in the hands. The degeneration could eventually have an effect on your breathing.
I recently watched my 88-year-old mother-in-law go through this process over a 3-4 year period. All of the doctors thought that the lower extremity numbness was a result of her diabetes. We kept after the doctors until the stenosis was discovered and they did the decompression surgery. Unfortunately, the damage was already done and she is now in an electric wheelchair. I don't want that to happen to anyone else.
The nerve damage occurring because of the stenosis is considered a spinal cord injury.
Long-term use of pain medications will result in constipation, liver and/or kidney damage, weakening of the ability of the body to produce its own pain endorphins.
In my opinion, all of the symptoms including the headache could stem from the fall and the resulting fracture.
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QUESTION: Dear Dr.Ryan
I am very sorry to take up so much of your time,but I would like to type out my MRI's of my head,neck and back for your opinion.
Head MRI:
There is several rounded high-signal foci seen within the deep white matter of both cerebral hemisphere's.These involve the corona radiata and centrum semiovale,bilaterally.I see no evidence of a signal abnormality existent within the corpus callosum.There is not associated mass effect.The ventricular system is symmetrical and nondilated.Normal vascular flow voids are visible.
Impression:
Today's examination shows nonspecific high-signal changes present within the deep white matter of both cerebral hemisphere's as described.These may be silent ischemic related,however,the differential does include multiple sclerosis.
Neck MRI:
Findings:
There is solid fusion of the C4-5 disc space.There is a visually obvious cervical spinal stenosis between the C3-4 disc space and the C6-7 disc space.Posterior contour bulges are seen at the C3-4,C5-6,C6-7 disc spaces,these bulges appear slightly more prominent on the left side of the midline.There is severe effacement but not complete obliteration of cerebrospinal fluid around the cord in the area of the narrowed vertebral canal.There is flattening of the normal cervical cord expansion in this area.Axial imaging at C2-3 demonstrates no significant abnormality,axial imaging at C3-4 demonstrates annular disc bulging,bilateral disco osteophytic protrusion producing severe lateral recess and foraminal stenosis and there is obvious cord flattening at this level.Axial imaging at C4-5 demonstrate a flattened contour of the cervical cord with some thickening of the posterior longitudinal ligament and mild symmetric C4-5 foraminal narrowing.Axial imaging at C5-6 demonstrates asymmetric predominantly left-sided disco osteophytic protrusion producing severe left-sided foraminal narrowing.On the right,there is no significant foraminal stenosis.The degree of foraminal stenosis on the left side is most severe at this level.Axial imaging at C6-7 demonstrates a moderate left paracentral disc protrusion superimposed on generalized annular disc bulging.The protrusion is focally indenting the cord.It does not extend as far peripherallly as the lateral recess and foramen.There is mild bilateral foraminal narrowing at this level caused mostly by annular bulging.
Impression:
Comparison with the previous exam of April 2006 demonstrates persistance of multilevel cervical spinal stenosis between C3-4 and C6-7.The degree of stenosis has not changed.Severe bilateral foraminal stenosis is associated with this at C3-4 and left-sided severe foraminal stenosis at C5-6.Mild bilateral stenosis of the foraminae is seen at C4-5 and there is a moderate left paracentral disc protrusion at C6-7 indenting the cord but not causing any major foraminal narrowing.All these findings have remained unchanged.There is definite cord compression from the combination of degenerative and postsurgical changes but there is no definite increased cord signal to indicate significant compressive myelopathy.
Back MRI:
Findings:
On sagittal imaging,there is significant degenerative retrolisthesis of L4 upon L5 by 0.7cm.This is similar to the appearance on the preoperative MRI's dated September 1997.The L4-5 disc space is markedly narrowed and shows extensive Modic type II endplate changes(fatty change).On sagittal images,a disk herniation which is seen at this level extending along the posterior margin of L5 and is on the left side,and actually looks very similar to the preoperative images from 1997,perhaps a bit smaller.On sagittal,a left posterolateral disc herniation with inferior extension along L5 is noted,again very similar to the preoperative appearance although not quite as rounded and discrete.It does however suggest a recurrent left L4-5 posterolateral extruded disc herniation.The thecal sac is deformed extrinsically by the disc lesion although not quite as marked as on the original preoperative exam.There is moderate L4-5 facet joint osteoarthrosis.Also noted is a right sided L5-S1 foraminal disc protrusion.
Your opinion on these mri findings would be greatly appreciated.I certainly do not feel very good some days,even with the medication.Doctors have determined that I will never work again.I was hoping that some surgical intervention would give me some more quality of life.At this point,a surgeon says it is not recommended,which I find very hard to accept.
Sincerely
Robert
ANSWER: In reviewing your MRI results, my opinion remains the same. I did notice that there is also a stenosis (narrowing) in some of the foraminae (the openings in the vertebra that allow the nerves to go out into the body.) That can cause pain from pinched nerves and it is much more difficult to deal with surgically. In addition, surgery may not be advisable now because of the fusion area being the central location of the narrowing. The MRI shows no significant changes in the past year and surgery carries its own risks of making the damage worse.
I still recommend that you get complete, thorough answers from your doctor on your specific case. You have rights as a patient to have your questions answered and your pain problem addressed.
Thank you for your question, Robert. I hope that my answer was helpful again to you.
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QUESTION: Dear Dr.Ryan
I cannot thank you enough for your opinions.It certainly has helped in understanding what is going on and what I may expect in the future.I would like to ask you what you meant when you said:In my opinion,all the symptoms including the headache could stem from the fall and the resulting fracture.It is just the fracture part I do not understand.Would you be so kind as to explain the resulting fracture part for me.I understand that you are extremely busy and in my opinion very knowledgeable and extremely valuable to all the people you are helping.I commend you for all you do.
Sincerely & Greatly Appreciated
Robert
AnswerI had answered this question in a previous letter but it must have gone off to some internet Bermuda Triangle.
A fracture is the medical term for a broken bone. Your neck was fused together at C4 and C5 which means that one or both of those vertebra (bones in the spine) was broken during your fall.
Thanks again for your question, Robert. I hope that my answer gives you the information you need.
