Dr. Wise, would this cause pain?

[calico]

I was reading my cervical laminectomy surgical report (C5/6-C6/7) and it talked about lots of clearing out of calcification. One statement was that they worked on "removing a significantly calcified portion of the posterior longitudinal ligament." It goes on to say that "the thickened ligamentum was seen to be firmly applied to the dura, and a portion of it was left here, as the dura was seen to be very thin . . .however, the decompression was in fact achieved."

Presumably, this firm attachment of the ligamentum to the dura still exists 6 years after the decompression, however my MRI's have no findings (no current compression or myelopathy.)

My questions are:

1) Would a thickened ligamentum firmly applied to the dura be objective medical evidence as to why I have chronic neck/arm pain?

2) Would this sort of condition show up on an MRI?

Thank you for your thoughts,

Calico

[David Berg]

Calico,

I'm sure Wise will have much more useful information, but in the meantime you might want to do a search on information about OPLL (ossification of the posterior longitudinal ligament). A search on Google or Medscape will give you plenty of material to browse. It sounds like this info might be useful to your situation.

[dejerine]

Dear Calico,
This post is for educational purposes only and is NOT medical advice.

OPLL is a progressive condition, the cause of which is unknown. The disc contains proteoglycans, which are irritating to surrounding tissue, and at least one Japanese author thinks this is the cause of the calcification.

Passing on causation, I know of not a single case of OPLL which was diagnosed correctly unless the calcification was almost entirely through half the spinal canal. It IS identifiable on MRI, but more by the irregular shape than anything and is almost universally misread on MRI as an osteophyte, or bone spur.

If the OPLL had been taken off the dura, there might have been a tear, which are hard to repair, with a fluid leak resulting. Few neurosurgeons would approach such a task without nervousness.

CT without contrast is said to be the best study for OPLL but the bone windows must be set on the machine to look for it. Many OPLL masses are much bigger than the films reveal because only slight hypertrophy can compress cord as easily as hard bone, since the cord is about the consistency of pudding.

I am a voice in the wilderness on compression. Dr. Young will probably swat me for saying this, but I do NOT believe good objective tests exist for detecting and measuring SLIGHT cord compression. Traditionally this has been pronounced NO compression, although some indentation of the cord can be seen. I have never understood this. I think it unlikely that electrophysiologic testing would call this normal, IF such test existed, which they do not. Pain in that area comes from a little nerve which loops back in from the ganglion outside the foramina and since it is RIGHT THERE where the compression is, I have wondered if local neuropathic pain is possible from that, similar to what is theorized in trigeminal neuralgia. You will find NO ONE who agrees with me, however, you can at least tax your doctor with the question, but you will be an outlier since medicine has never considered this question. I have similar pain and also have OPLL, so of course I am driven ask this question, but then, the context for a proper answer does not exist, in my opinion. Do not rely on what I say nor believe me since I am guessing wildly, unfortunately.

[Wise Young]

calico, I agree with dejerine that the standards for "slight compression" are very vague and variable amongst doctors. On the other hand, from your description, it is clear that your doctor did his/her best to remove as much of the posterior longitudinal ligament as possible. Because of the attachment to the dura and the thinness of the dura at the attachment point, they correctly decided not to remove all of it because of fear of a dura tear. Some neurosurgeons may open the dura, remove the attachment, and repair the dura with a graft but I assume that your doctor was not prepared to do that. Regarding whether the ligament might be the cause of your pain, I don't know. Some people have it without pain while others seem to have pain even with no MRI evidence of compression. The presence of neuropathic pain may be more related to changes in the spinal cord than to the presence of continuing compression. As you know, spinal cord injury itself may contribute to the development of neuropathic pain. Not all people who have neuropathic pain have continuing compression. I am not sure that removal of the remnant ligament would eliminate the pain.

Wise.

[calico]

The reason I asked this question is my disability company keeps demanding from my doctors "objective medical evidence" of my continuing pain.

The company was happy to approved me in 1997 when I had an MRI that showed "1) severe spinal stenosis at the C5/6 level with a central disk protrusion and high signal changes in the spinal cord suggesting edema vs. myelomalacia; and 2) moderate spinal canal narrowing at the C6/7 level due to spondylosis."

Two years after my surgery (1999) my MRI showed "no evidence of cord edema or myelopathy, or cord compression". Yet the pain had continued unabated, no improvement! But the fact that my complaints have been consistent for 6 years is not enough for the disability company, they still want "objective medical evidence", so I keep looking for things in my records, or some kind of test, which might meet that criteria.

Any ideas on how to do this are appreciated. Sometimes I think I need some doctor who is qualified to stand up to them and say, "Look, folks, this patient's history accounts for her continuing arm/hand pain. A clear MRI does not indicate that X, Y, and Z haven't happened to her spinal cord, but her history, combined with her complaints, is objective evidence that X, Y and Z have happened with a high probability." I don't know that I have a doctor who feels competent enough in this area to do that, and I still don't know if it would satisfy them.

Seems like all along the way here I've had to battle for credibility. When I first started having problems, the neurologist REFUSED to send me for an MRI. Hell, it was an ENGINEER at work who suggested to me that I needed one. He and another ENGINEER had been talking, and decided since my problems were bilateral it may be coming from my neck! But NOOOO, said the neurologist, it's just a little tendinitis, even after the skin burning pain started! Now the insurance company wants to ignore my history. It's not enough once again!

Thanks for letting me rant!

Calic

[Wise Young]

calico,

There is a condition called SCIWORA. This is an acronym that stands from "spinal cord injury without radiological abnormality". It happens, particularly in children.

I don't know whether such a term exists but pain without radiological abnormality (PWORA) is very common, as the following web sites show:
http://www.drlamb.com/painbeforex-rays.htm

In one 1991 study (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1932970&dopt=Abstract&holding=f1000) that examined 100 patients with back pain in London, 34% had no evidence of radiological abnormality. Even in patients who had radiological abnormality, the pain score and radiological diagnosis was not significantly correlated.

Most cases of Complex Regional Pain Syndrome (CRPS) have no detectable CT or MRI abnormality. In fact, this is almost the definition of the condition. So, it is a matter of your doctor providing the appropriate diagnostic category for your insurance company.

Wise.

[dejerine]

Calico, perhaps you could talk to a worker's comp attorney and ask for names of docs who are willing to do the kind of work you need.

[This message was edited by dejerine on 10-21-03 at 01:44 PM.]

[calico]

About 9 months ago, my disability insurer sent me for an "independent medical exam" (an exam by a doc who's never layed eyes on me before). Between what I brought him and what the insurer had sent him, he had a boatload of info on my history/symptoms.

He describes in detail the records from my neurosurgeon (the guy who fused C5/6-C6/7 in 1997), describing feeling of chemical burning on both extremities, intermittent lightening-like sensations down both arms, subtle decrease to pinprick in both hands, bilateral Hoffman's sign (whatever that is), severe cervical spinal cord compression with radiculopathy, evidence of myelopathy including loss of hand function with reflex changes. The neuro felt there was a significant neuropathic component to my pain which may be sensory to the nature of the involvement as the roots leave the spinal cord.

I've been having these same complaints for 6 years and the IME stated that.

Are you ready for this? In the NEXT PARAGRAPH, the IME states his conclusion:

"Chronic upper extremity pain of uncertain etiology. Her symptomology and physical findings fit neither RSD nor NEUROPATHIC pain, based both on the nature and character of her complaints, the physical examination and the nonanatomical distribution of her discomfort. The only objective finding is relative weakness of right grip strength."

My insurer had asked him to assign an ICD-9 code and he said he couldn't due to the uncertainty of my diagnosis.

Well, my insurer loved this and has been using it in letters to my docs who fortunately understand that I'm being set up.

I've gotten a lawyer and hope he can guide me qualified experts who know how to play the game back.

Again, thanks for letting me rant!

Calic

[Wise Young]

Calico, I am no expert at this but there must be some way that you can appeal this determination by the insurance-company appointed doctor. Wise.

[calico]

You're right, Dr. Wise, I think it just takes lots of hard-headedness (one of my virtues ?http://sci.rutgers.edu/forum/images/smilies/smile.gif), a lawyer who bills you every time they burp, supportive docs, and probably some new "experts" who will write what anybody on this forum could write, i.e. the causes and symptoms of neuropathic pain.

Thanks for your support on this. I've encountered many people at this point who get this kind of treatment so I know I'm not being picked on "special".

I just can't seem to get over being stunned at how ignorant many (most?) physicians are about neuropathic pain. Giving this IME the benefit of the doubt, that he's not being "bought off" by the insurance company, don't you think after many years of practice he would know it when he sees it? This is a rhetorical question. I guess I'm thick-headed because some things are just incomprehensible to me.

Calic

[dejerine]

Calico, email me at registrant1@comcast.net