Cervical pain and limitation of movement after 2 cervical spine surgeries
The patient, 43 year old, used to be very physically active and carry a large amount of equipment on him.
For the last 5 years he suffers from pain at the cervical spine that is accompanied by feeling of pressure in this area and radiation to the back of the neck that are accompanied by a feeling of pressure and swelling in the neck. The pain radiates to the right hand, until the second finger and is accompanied by a sense of vibrations in the arm and a sense of burning in the second finger. He also suffers from a sense of lower extremities stiffness that is accompanied by a sense of edema in the thighs, a feeling the chest is prolapsed, and a feeling of numbness.
A work up was done which included clinical and imaging tests. It was demonstrated that these complaints are caused by neural damage of a myelopathic type caused by anterior pressure on the cervical spinal cord, caused by a disc and an osteophyte that were developed in the area, and caused damage to the spinal cord that is manifested in the MRI as a syrinx.
He was operated twice for the release of pressure in the spine. In the first surgery that was done 2 years ago, the disc and the osteophyte were removed and an artificial disc was implanted anteriorly. Since the surgery have not improved his condition, a second surgery took place after an year, where decompression was completed anteriorly, and instead of the artificial disc, a fixation was done using a frame and a plate.
Despite the second surgery, his subjective and objective condition have not changed.
1. What is the preferred way of treatment ?
2. Conservative versus surgery ?
3. Prognosis of each way ?
4. Risks of a 3rd surgery ?
5. Risks of not having a surgery ?
Until present the patient was healthy. He served in the military in an active duty. His service involved continues physical activity and of carrying heavy loads of equipment. The weights that were carried by him were up to 40 kg. Also, the special unit where he served used special high impact helmets that weighed 1600 grams. He also carried weapons and thermal quipment that weighed another 10 kgs. These efforts were carried out in training and in operational duty.
5 years ago he started to feel kind of vibrations in the left arm and felt contractions in the upper back muscles. The patient was treated with pain killers, NSAIDS and physiotherapy, but with no relief. He has gone through a rheumatologic work-up that was negative. Due to worsening of the above complaints an MRI of the cervical spine was performed.
The MRI has demonstrated anterior pressure on the spinal cord, especially at C5-C6, by the disc and an anterior osteophyte that caused pressure and damage to the spinal cord that was manifested in a local syrinx.
Following that finding, and neurological findings in 4 limbs, it was recommended that he would pass an operation. 2 years ago he had a surgery. In the surgery a discectomy and artificial disc replacement was performed.
The surgery made no improvement in his symptoms and a month later he felt pain and pressure in the back of his neck. A repeated MRI has demonstrated remains of pressure at C5-C6 with an osteophyte and a remain of disc, and due to the above he had a second surgery an year afterward. In the surgery (anterior approach) the artificial disc was removed, completion of the removal of the anterior pressure and fusion of C5-C6 with PEEK and Titanium plate was preformed. This surgery also had not changed his condition and he is treated since with physiotherapy and hydrotherapy, but with no significant improvement.
The last MRI has demonstrated posterior syrinx to C6-C7, S/P fixation of inter vertebral space C5-C6 with local artifacts, C5-C6: “at this height, narrowing of the cord, posteriorly by hypertrophy of posterior ligaments and anteriorly by an osseous component , osteophyte that protrudes dorsally, now more on the left than the right”.
The patient feels limitations of movement in the cervical spine, feels pressure in the lower neck and shoulders. In the evening he has pain in the back of his neck that radiates with feeling of swelling in the neck. He also feels numbness around the mouth. The patient feels pain which radiates to the right hand until the second finger with feeling of burning in the second finger. He feels “vibrations” in his left arm and pain that exists along the left arm up to and including the second finger. He suffers from tremor in his hands. He feels edema in the heels and feeling of pain and stiffness behind the thighs and calves.
A surgical scar in the left anterior neck, 7 cm long and 1-2 mm wide.
Reports of sensitivity in the central posterior neck, the paravertebral muscles and the inner border of the scapulas. Movement of the neck have revealed turn of neck with the chin until a distance of 5 fingers from the chest. Straightening of 10° and painful. Bending of 20° to the right and 30°to the left. Turning to right 30°, to the left 45°. Complains of decreased sensitivity in inner side of arms (more on the left), decreased sensitivity on the ulnar side of palms of hands (more on left). There is a slight spastic weakness of upper and lower extremities muscles, especially the distal in hands (interosseous and finger flexors). There are myelopathy signs with hyperactive reflexes in all 4 extremities and pathological reflexes including Babinski’s sign on right, Hoffmann’s sign in 2 hands (more on right), and inverted brachial reflex also more on right side.
1. Bone scan 8 years ago demonstrates increased absorption at sacroiliac joint, lumbar vertebras and some ribs.
2. Bone scan 4 years ago demonstrates increased absorption at T10-T12, anterior L4 and SIJ’s.
3. CT Cervical Spine - 2 years ago demonstrates status after anterior surgery at C5-C6. An intervertebral fixator is seen, and a posterior osteophyte that protrudes the spinal canal and presses the spinal cord
4. CT Thoracic spine - 10 years ago and 6 years ago demonstrated Schmorl’s nodes in some of vertebral bodies accompanied by degenerative changes and wedge shaped distortion of T4 post fracture.
5. CT Lumbar spine - repeated every 2 years for the last 10 years demonstrated Schmorl’s node on upper margins of L5 and disc protrusion at L5-S1 to right posterior.
6. MRI - Thoracic spine –10 years ago – demonstrates distortion after wedge shaped fracture of T11 without evidence of pressure on neural structures.
7. MRI – Cervical Spine - 3 years ago - demonstrates degenerative changes with disc protrusion at C4-C5, C5-C6 and C6-C7. Most pressure seen at C5-C6 and at C6-C7 a small syrinx.
8. EMG –
A) 8 years ago - normal test.
B) 6 years ago - demonstrates major damage to nerve roots at L4-S1 with decreased of recruitment, wide potentials and polyphasic.
C) 5 years ago - demonstrates chronic root damage
D) 3 years ago - 2 EMGs -the first demonstratws signs of carpal tunnel syndrome on 2 sides, the second demonstrates chronic neuropathic signs especially according to C7.
E) 1 year ago- the same as 3years ago.
9. MRI – Cervical Spine -
A) 2 years ago - demonstrates posterior and left disc herniation at C4-C6 and C6-C7, narrowing of cord at C5-C6, hypertrophy of posterior ligaments with a posterior osteophyte and disc herniation, especially to the left.
B) 1 year ago - demonstrates posterior syrinx to C6-C7 and artifacts after fixation at C5-C6.
I reviewed his reports and radiographs twice and considered my involvement with similar patients over the past 20 years before generating this response.
I understand him to be a 43 year old male who was, in the past, very active. He was in the military where he performed strenuous physical activity. Approximately 5 years ago he began to experience neck pain. This was associated with a "pressure-like" sensation. Over time, these symptoms worsened prompting him to seek medical attention. Associated symptoms included parasethias and dysesthesias in the arm and hand, as well as the chest and thighs.
The medical evaluation included laboratory evalustion which was unremarkable, and a cervical MRI. The cervical MRI that was performed 5 years ago demonstrated, to my interpretation, a small cervical syrinx and associated C5-6 disc/osteophyte complex.
In light of the symptoms and radiographic findings, he underwent C5-6 discectomy with artificial disc replacement 2 years ago. This surgery was not effective in relieving his symptoms. A second surgery an year later after a repeat MRI. This surgery included removal of the artificial disc and further extension of the discectomy to include partial corpectomy. An instrumented fusion was performed.
The fusion appeared to be radiographically successful but the patient's symptoms were unchanged. Follow-up studies have demonstrated mild disc bulges above and below the arthrodesis. The patient has persistent symptoms of neck pain and dysesthesias in the limbs including numbness, pain, vibratory-like sensations, and burning sensations. His examination demonstrated slightly reduced cervical range of motion, decreased sensitivity in the C8 nerve distribution, mild spastic weakness of the upper and lower extremities and diffuse myelopathy with pathological reflexes.
The diagnosis is myelopathy. This is confirmed with the MRI showing the syrinx and the patient's symptoms and signs. The syrinx in the spinal cord represents a loss of neural tissue, presumably from trauma. The resultant spinal cord dysfunction from the syrinx is manifested as spasticity, sensory changes and pathological reflexes.
Surgical decompression of the spinal cord was performed twice without improvement in signs (presumably) or symptoms. There is no existing means in the US of "rebuilding" the spinal cord with new neuronal cells which is what would be required for successful surgery. There is a company in Israel called Proneuron that had an experimental trial examining the placement of cells in injured spinal cords, but I don't know the success of the trial. There has been some research using electrical impulses via surgically inserted wires to the spinal cord (EBI Inc, Parsippiany, NJ, USA) to improve spinal cord function with modest improvement.
I don't believe that further surgical decompression will improve the patient's symptoms as he has already demonstrated loss of neuronal tissue. I would recommend continued non-surgical treatments including physiotherapy and pharmaceutical management (Baclofen, Zanaflex). The patient should be followed with serial cervical MRI scans to assess the syrinx. If the syrinx were to enlarge, a surgery to decompress the syrinx (syringo-subarachnoid shunt) could be considered.