neck pain after cervical fusion

[dejerine]

Dr. Young, I have had C5-7 fusion and the disc above at C4-5 has slowly been creeping back against the cord so that now it is indented slightly. I know this presses on the anterior spinal artery or just compresses the cord so blood can't get out, but the doctor says it is "not significant". I have had serious pain since the fusion and was told it was due to loading on that disc/motion segment at C4/5. How do radiologists determine exactly WHEN cord compression is significant.

[Wise Young]

dejerine, I am sorry to hear about the disc extrusion and your pain. Criteria for judging whether a disc compression of the spinal cord is "significant" or not vary widely. Doctors do not agree on the criterion, even after acute spinal cord injury. Some doctors claim that it does not become significant until the spinal cord is compressed by about a third of its diameter. On the other hand, I have seen some patients who have neurological loss and pain with much less compression. Over the years, I have come to the conclusion that compression is not the only problem when there is an extruded disc that is impinging on the spinal cord. There is also inflammation, adhesion and tethering of the spinal cord, as well as possible reduction of blood flow.

Compression of the anterior spinal artery is probably not as great a problem in the cervical spinal cord as it is in the thoracic spinal cord because blood flow can come from two directions in the cervical cord (above and below). On the other hand, tethering and adhesive scars between the dura and spinal cord may occur and reduce blood flow.

One of the major problem with fusion is that it eliminates the ability of the segments to bend and concentrates the movements of the neck onto the segments that can bend. This produces greater wear and tear on those discs. This is the primary cause of what is called the "failed back syndrome".

I can understand the reluctance of your doctors to operate, to fuse the C4/5 disc because this would just put additional stress onto the C2/3 segment. Most neurosurgeons that I know would want to postpone surgery for as long as possible, as long as there is no progressive neurological deficits associated with the disc.

I have a few questions:

1. Have you had a laminectomy in the C5-7 area? How much room in your spinal canal? If your spinal canal is narrow, perhaps a laminectomy would help, to give the spinal cord more room. During that operation, they may find some adhesions and perhaps clear them.

2. Where is your neck pain? Does it get worse with movement? Is there a particular position where the pain is minimized. The reason that I ask is because you might have some abnormal movement of your C4/5 segments. Is it tender i.e. hurt when you push (gently) on that part of neck?

3. Do you have spasticity and neuropathic pain (burning pain below the site), etc. ?

4. How bad is the pain?

Wise.

[dejerine]

Dr. Young, Thank you for reply. Neutral position best. Pain area is occipital head and neck bilaterally and helped by clonazepam. It IS tender to push on C5, or to rotate head up or down, or side to side.Must sleep face down to minimize pain.

Had anterior interbody fusion with corpectomy and strut graft, but no laminectomy. Canal is not narrow side to side, indicates room and room behind cord but anteriorly the extrusion appears to be touching cord on CT/MRI.

No tethering or arachnoiditis seen on MRI, but not sure resolution power enough to always see this. I do have latency on SSEP, and I lack balance, and the front of the cord is missing in a dished out fashion at C5, C6. (looks like kidney bean)

Pain in neck does not feel neuropathic (bizarre) so suspect discogenic, but unless the recurrent nerve coming in from the ganglion is somehow inflammed I don't know source. If I have been bad to my neck by moving too much,the pain extends up into lower jaw and is relieved by resting neck in recliner for a day or two,so something mechanical about causation.

In addition, I have very severe CP which is all I can handle and then some. Can't wear clothing without agony. Can't stand sheets. Extremes of temp or temperature change cause pain but direct blowing of A/C in car evokes it the easiest. Sensation includes burning from light touch with elements of cold and wetness on face and distal extremities, muscle cramping,lancinating pain, and definite neuropathic pain with bladder filling. I really think my neck pain is nociceptive, but it is bilateral, making me suspect motion and position are doing it so it seems anatomical.

[Wise Young]

Your neck does sound like real discogenic pain. However, the allodynia that you describe is strongly suggestive of neuropathic pain. Let me cogitate on this for a while. I don't have any good suggestions right now. Wise.