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Thread: post C3-4, C5-6 anterior fusion questions

  1. #1
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    post C3-4, C5-6 anterior fusion questions

    Last July I took a very minor fall forward and two days later noted numbness on the bottom of my left foot. Within two or three days I noticed that the numbness had traveled up my left leg and up the left side of my torso stopping just below my rib cage. My symptoms progressed to lack of termperature sensation and a burning/stinging sensation in my foot and leg.

    To make a long story short, after receiving initial diagnoses of syringomyelia and then possible MS, it was finally determined by a neurologist at UCSF in California that my problems stem from cervical stenosis. Apparently in the fall I suffered a cord stroke in the spinothalamic tract at C3-4. My symptoms progressed to numbness and tingling in my left torso and across the tops of my shoulders and upper arms, and numbness and tingling with severe burning/stinging in my left hip, leg, and foot.

    I had anterior decompression/fusion surgery on December 17, 2003, with arthrodesis. My neurosurgeon said that the cord was badly compressed at C3-4 to the extent that when she removed the disc a visible indentation was present on my cord which then sprung back within seconds. The surgery went well and I was only in the hospital one day. I wore a philadelphia collar 24 hours a day for two weeks. I felt better in the hospital with reduced numbness on my shoulders, arms and torso and reduced stinging in my legs. I was advised that my symptoms probably would not get better because of the damage to my spinal cord, and that the surgery was to prevent catastrophic injury. I had been taking Neurontin at 600 mg. every 8 hours. Following the surgery my NS instructed me to reduce the Neurontin 600 mg. every week to see where things are.

    Within a week after returning home the burning and stinging in my left leg and foot increased. By the time I returned to my NS it was almost unbearable and she told me to go back to the original Neurontin dosage.

    I returned to 2400 mg, but the pain remained and she then told me to increase up to 3600 mg as needed. I am at 3000 mg and the pain remains constant. I also have a lump at the surgery site and my voice remains hoarse. My neck now hurts at the base. My NS has said we need to see how things work out with time.

    Is this normal for the pain to get worse? Is it normal for the hoarseness to continue for a month? Is there any chance my symptoms will get better with time? The pain goes away when I sleep and I literally feel it waking up with me when I wake up. I have been told that this is because the signal my damaged spinal cord is sending to my brain that there is pain in my leg with no cause, shuts down when I sleep. Is there any way to shut this signal down when I am awake? I am overweight. Will losing weight reduce my chances of developing degenerated discs and stenosis in other areas? I appreciate any input anyone has to offer.

  2. #2
    Your surgery was a month ago... I wouldn't despair. I had a C5-7 fusion performed in Jan.'99... throughout the duration of my rehab days (3 months-ish), I had shooting pain in various places that was ridiculously annoying. Even the slightest touch hurt at times (in my arm for some reason). I was on Neurontin, close to 900 or 1100mg I think. Eventually the pain subsided, and I weened myself off every drug I was taking. Now I don't take anything but vitamins & supplements.

    Basically your body is going to need a little bit of time to recover from the trauma & surgery. I'd say it's normal. It will more than likely get better with time.

    However, if there is something specific & you are concerned, do seek out a professional advice. It may be dangerous to just take the attitude that things will subside, even though I firmly believe they will.

    re: a lump at your surgery site... is it hardware or something like swelling?

    hang in there...
    ~ scott

    ______________
    There will be plenty of time to rest when I'm dead and gone, until then, 150% straight ahead....

  3. #3
    jovichlaw,

    Your cervical spinal canal is probably narrow and may still be constricting your spinal cord. Unfortunately, what you are facing is the limitations of spinal surgery for treating spinal stenosis. Surgery causes scarring and reduces flexibility of the spine, both of which tend to aggravate the problem. Surgical approaches of the future are likely to result in less compromise of spinal flexibility and less risk of damage to the spinal cord. Therefore, as long as you do not have clear localized compression of your cord, your goal should be to minimize surgery.

    Are you scheduled for another MRI? You should probably get another one to check on the status of your syringomyelic cyst and your other intervertebral discs. As I understand from your description of the surgery, you had anterior decompression only without untethering. Expansion of the syringomyelic cyst may explain the increase in your neuropathic pain. Your neurosurgeon is understandably hoping that things will settle down and your pain can be controlled pharmacologically. Her next option is a posterior decompression but your choices after that point are very limited.

    Things should get better with time. I know some people who have lumbar stenosis and it often take 6 or more months for the pain to subside after surgery. Reducing body weight should help in three ways. First, carrying less weight around should reduce the stress on the rest of your spine. Second, losing weight reduces the bulk of all tissues in your body. Third, exercise should improve blood flow of the spinal cord. All of these should reduce pain from the cervical stenosis and prevent further problems.

    The other problems that you describe should be looked at. For example, is the lump at your surgery site hard or soft? Have you had a consult to look at your larynx? Did you have damage of your vocal cords and can it be fixed? Finally, regarding neurontin, I have known some people who have gone to 4200 mg or higher per day for their neuropathic pain; the limitation is side-effects of the drug.

    I hope that this helps.

    Wise.

  4. #4
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    Thank you Dr. Young and Scott. I guess I should clarify - it turns out that I do not have a syrinx or MS. Fortunately those initial diagnoses were ruled out and it was determined that all of my symtoms are a result of the spinal cord stroke in my spinothalamic tract. What the first neurologist and the radiologist who read my MRIs thought was a syrinx from T5-T11 turned out to be embryonic cord remnant and not a syrinx (whew). What they thought might be MS plaque in my spinal cord turned out to be the ischemia from the stroke. A brain MRI was completely normal showing no MS (also whew).

    I did not even have any symptoms from the stenosis. I did not know my cord was compressed until the fall which led to the cord stroke and the resulting damage.

    The lump at the incision site is hard and immovable. I was not told there was any damage to my vocal cords or larynx, and she said the hardware is not detectable under the skin so I don't know what this is. 3-5 days after the surgery I had a great deal of trouble swallowing and breathing while sleeping while laying down. I would wake gasping for breath. It felt as if my airway would collapse when I became relaxed while laying down and I had to sleep in a recliner for several days. Then it got better. My NS said it was just swelling from the intubation and the fact that things had to be moved around to get to my spine. She said it would take time for things to get better and settle down, but I am concerned about this lump and the fact that my voice is now not getting better. For my voice to be normal I have to whisper otherwise it is hoarse and I sound like an adolescent boy whose voice is constantly cracking. I cannot yell or raise my voice without it cutting out or waivering. It is very odd.

    I return to my NS on the 27th and will discuss these issues and request a follow up MRI. I had an x-ray on 12/30 and she said everything looked fine in terms of alignment and the positioning of the plate and screws.

    She has told me that the fusion will not be complete for 3-6 months. I am a novice to all of this. I have never had surgery and was rarely ever to the doctor before this. Now I am fearful that my body is turning on me. I will take your suggestions about losing weight. I want to do anything to minimize my chances of having further complications.

    Where is the research and development in terms of the use of artificial discs rather than bone for disc replacement? I fear that the discs above and below the fusion will also deteriorate and need to be replaced at some point. What do they do when your entire neck needs to be fused? The thought of it scares the hell out of me.

    Thanks for your help.

    *Linda J*

  5. #5
    jovichlaw posted 01-18-04 04:51 PM
    it turns out that I do not have a syrinx or MS. Fortunately those initial diagnoses were ruled out and it was determined that all of my symtoms are a result of the spinal cord stroke in my spinothalamic tract. What the first neurologist and the radiologist who read my MRIs thought was a syrinx from T5-T11 turned out to be embryonic cord remnant and not a syrinx (whew). What they thought might be MS plaque in my spinal cord turned out to be the ischemia from the stroke. A brain MRI was completely normal showing no MS (also whew).
    • It is good that you don't have a plaque or syrinx. I am not familiar with the terminalogy of "embryonic cord remnant". They must be referring to a neurenteric cyst. This is a relatively rare presentation. I attach a few abstracts of recent reports. I wonder why you had the stroke in the first place. Do you have hypertension? If it were due to arteriosclerosis, it is doubly important for you to lose weight, reduce cholesterol and triglyceride levels, etc. If you have cervical spinal stenosis, the main reason for the pain is ischemia. For example, people who have arteriovenous malformations (which cause ischemia) develop pain, mainly because of ischemia.

    The lump at the incision site is hard and immovable. I was not told there was any damage to my vocal cords or larynx, and she said the hardware is not detectable under the skin so I don't know what this is. 3-5 days after the surgery I had a great deal of trouble swallowing and breathing while sleeping while laying down. I would wake gasping for breath. It felt as if my airway would collapse when I became relaxed while laying down and I had to sleep in a recliner for several days. Then it got better. My NS said it was just swelling from the intubation and the fact that things had to be moved around to get to my spine. She said it would take time for things to get better and settle down, but I am concerned about this lump and the fact that my voice is now not getting better. For my voice to be normal I have to whisper otherwise it is hoarse and I sound like an adolescent boy whose voice is constantly cracking. I cannot yell or raise my voice without it cutting out or waivering. It is very odd.
    • You should ask your neurosurgeon about the hard lump. Sometimes it may be a stitch. It should be relatively easy to fix. Regarding your hoarseness, to reach the C2-3 vertebrae, your neurosurgeon probably had to move your trachea to the side. This may have bruised the structures. They also must have intubated you. If the hoarseness does not go away, you should ask to see a laryngologist to take a look to see what is going on.

    Where is the research and development in terms of the use of artificial discs rather than bone for disc replacement? I fear that the discs above and below the fusion will also deteriorate and need to be replaced at some point. What do they do when your entire neck needs to be fused? The thought of it scares the hell out of me.
    • The next step would be a posterior decompression. Since you are already fused anteriorly, presumably at C2-3, a laminectomy at that level probably would not have much effect on the flexibility of your spine. Hopefully, if you take care with the other vertebra, you will not need to any more fusions.

    Recent abstracts on neurenteric cysts
    • Chang IC (2003). Thoracic neurenteric cyst in a middle aged adult presenting with brown-sequard syndrome. Spine. 28: E515-8. SUMMARY: STUDY DESIGN To report an unusual presentation of a thoracic neurenteric cyst.OBJECTIVES To increase knowledge about the pathogenesis and treatment of intraspinal neurenteric cyst.SUMMARY OF BACKGROUND DATA Intraspinal neurenteric cysts (enterogenous cysts) are very rare congenital cysts of endodermal origin. The diagnosis usually is established during the first or second decade of life. Those cysts are frequently associated with vertebral or spinal cord anomalies and dual malformation with mediastinal or abdominal cysts.METHODS A 50-year-old man presented with 1 year of left midthoracic intercostal pain after chest compression injury. Several months before admission, he felt left lower extremity weakness with right-side numbness. Plain radiography of thoracic spine was normal while MRI showed a cystic mass at T7, T8 level ventral to the spinal cord with cord compression. The spinal cord was displaced to the posterior more to the right side, mimicking hemisection of the left side of the spinal cord.RESULTS Thoracic laminectomy was performed and the intraspinal cyst was removed. The pathology report indicated neuroenteric cyst. The postoperative course was uneventful and the signs of myelopathy improved immediately. The patient appeared well after 2 years of follow-up.CONCLUSIONS Intraspinal neuroenteric cyst without plain vertebral anomaly may occur after trauma in middle aged adult life with Brown-Sequard syndrome. Successful treatment requires early recognition of those cysts and their associated abnormalities. Spine 2003;28;E515-E518.
    • Laidlaw JD (2003). Iso-intense neuroenteric cyst in the lower cervical spine treated with ventral resection and anterior fusion utilising sternal notch exposure: case report, technical note and literature review. J Clin Neurosci. 10: 606-12. Department of Neurosurgery and Department of Surgery, University of Melbourne, The Royal Melbourne Hospital, Parkville, Vic., Australia. A 36-year-old female patient with a long-standing asymptomatic lower thoracic scoliosis presented with sensory symptoms involving all limbs. MRI scan demonstrated a rounded ventral intradural mass causing major deformity of the cervical cord at C6 and C7 levels. Unlike most previously reported neurenteric cysts, the MRI signal characteristics of this mass were such that it could not be determined if it is cystic or solid, being iso-intense on T1- and hyperintense T2-weighted images. Resection was performed through a median corporectomy of C6 and C7, the lesion being found to be a neurenteric cyst with an attachment to the anterior median fissure of the cord. Strut graft and cervical locking plate fixation from C5 to C6 was facilitated by extending the cervical incision into the sternal notch, with detachment of left-sided strap muscle insertion. The patient made an excellent recovery with complete resolution of neurological symptoms and solid fusion. The postoperative course was complicated by an anterior cervical CSF collection which resolved spontaneously within 2 months. The literature regarding this rare condition and its management is reviewed. Although the majority of intraspinal neurenteric cysts are situated ventral to the cord, most reports of excision have been from a dorsal approach. Drainage and subtotal excision of neurenteric cysts have been previously advocated; however, the recurrence rate is such that complete excision is advocated. This is facilitated by a ventral approach. A simplified method of utilising the sternal notch exposure is reported. The literature regarding the anatomical peculiarities pertinent to the sternal notch approach, and the reported literature regarding spinal neurenteric cysts is reviewed.
    • Takase T, Ishikawa M, Nishi S, Aoki T, Wada E, Owaki H, Katsuki T and Fukuda H (2003). A recurrent intradural cervical neurenteric cyst operated on using an anterior approach: a case report. Surg Neurol. 59: 34-9; discussion 39. Department of Neurosurgery, Tane General Hospital, 1-2-31 Sakaigawa, Nishi-ku, Osaka 550-0024, Japan. The neurenteric cyst is an uncommon congenital lesion. In most reported cases, it has been operated on via a posterior approach using a laminectomy, despite the fact that the cyst is usually located ventral to the spinal cord. Reports have shown that early postoperative results have been good with the posterior approach, but very few studies of the long-term postoperative recurrence of neurenteric cysts have been conducted. Here, we report on a case of recurrent neurenteric cyst that was operated on using an anterior approach.A 42-year-old woman presented with a cervical neurenteric cyst that had recurred eight years after its partial removal via a posterior approach. The patient complained of pain on the lateral side of her upper arms, and an magnetic resonance imaging showed that the recurrent cyst was located ventral to the spinal cord and compressed the cord dorsally at the C4-6 level.The patient was operated on via an anterior approach using a vertebrotomy at the lower half of C5 and the upper half of C6. The cyst was attached to the spinal cord firmly and was subtotally removed, with the thickest portion adhering to the cord not being removed. The caudal end of the cyst was observed with the assistance of a rigid endoscope.A neurenteric cyst may recur after partial removal, and the patient's condition may deteriorate during postoperative follow-up. The anterior surgical approach provides good visualization and facilitates safe removal of the lesion.
    • Song JK, Burkey BB and Konrad PE (2003). Lateral approach to a neurenteric cyst of the cervical spine: case presentation and review of surgical technique. Spine. 28: E81-5. Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee, USA. STUDY DESIGN: The lateral cervical spinal approach is illustrated by a case of neurenteric cyst. OBJECTIVES: To present a case of a neurenteric cyst resected the lateral cervical approach, and to review the approach in detail. SUMMARY OF BACKGROUND DATA: Intradural lesions located anterior to the high cervical spinal cord may present a difficult surgical problem. Neurenteric cysts are unusual lesions found in the brain and spinal cord. This report presents a case of cervical neurenteric cyst causing anterior cord compression that was resected using the lateral cervical approach. METHODS: A 32-year-old woman presented with chronic headaches and worsening nausea, tinnitus, dizziness, and hyperreflexia and clonus in her lower extremities. Magnetic resonance imaging of the cervical spine showed a mass compressing the anterior spinal cord at C3. Pathology showed that this lesion was a neurenteric cyst. The lesion was resected using the lateral cervical approach. RESULTS: At this writing, 36 months after surgery, the patient has continued resolution of her symptoms, and no cyst recurrence has been shown on repeat MRI imaging. She has no evidence of postlaminectomy kyphosis. CONCLUSIONS: The lateral cervical approach is useful for surgeons attempting to resect lateral and anterior intradural lesions of the cervical spine. It also gives excellent cranial-to-caudal access to the thecal sac, spinal cord, and the lesion to be resected. The neck incision preserves cosmesis, and neuromuscular function is maintained. Spinal fusion was avoided in the reported case.
    • Paolini S, Ciappetta P, Domenicucci M and Guiducci A (2003). Intramedullary neurenteric cyst with a false mural nodule: case report. Neurosurgery. 52: 243-5; discussion 246. Department of Neurological Sciences and Neurosurgery, Ospedale Santa Maria, Terni, Italy. spao2@yahoo.com. OBJECTIVE AND IMPORTANCE: Spinal neurenteric cysts are rare congenital lesions that may occur either alone or in the context of a complex malformative disorder including typical vertebral and cutaneous abnormalities. The interest of the case of a spinal neurenteric cyst described here lies in its rare intramedullary location and in the false mural nodule image on the preoperative magnetic resonance imaging scan. A further distinctive feature is the association with a cleft spinal cord. CLINICAL PRESENTATION: A 28-year-old woman presented with a 2-year history of progressive paraparesis and urinary retention. A magnetic resonance imaging study disclosed a T8-T9 intramedullary cystic lesion with a mural nodulelike formation on the posterior face. INTERVENTION: A posterior midline myelotomy exposed a cystic lesion that had translucent walls and contained a milky fluid. No mural nodules were found. Once the cyst had been emptied, a collateral finding was a cleft that was clearly observed in the anterior spinal cord. The histological diagnosis was a neurenteric cyst. Retrospectively, the nodular lesion found on the preoperative scan was attributed to mucinous clots deposited at the bottom of the cyst. CONCLUSION: This case report demonstrates that neurenteric cysts can vary widely in radiological appearance, depending on the contents of the cyst. These differences become especially important if the associated stigmata are lacking and the preoperative diagnosis rests on magnetic resonance imaging scan appearance alone.

  6. #6
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    It is good that you don't have a plaque or syrinx. I am not familiar with the terminalogy of "embryonic cord remnant". They must be referring to a neurenteric cyst. This is a relatively rare presentation.
    They said that what showed up as a syrinx was a mistake in the radiologist's interpretation. What he saw as a syrinx, which showed up as a very thin area in the center of the spinal cord with no distention or displacement, is actually the central area of the cord which does not completely fill in while the embryo develops. At least this is how it was explained to me. Later it was actually traced all the way up my spinal cord. The neurologist I saw at UCSF, my neurosurgeon here in Santa Cruz, and Dr. Batzdorf at UCLA said they had seen alot of these mistakes by radiologists lately and Dr. Batzdorf has written a paper for publication in a radiology journal discussing differentiation between this cord remnant and syrinxes.

    I wonder why you had the stroke in the first place. Do you have hypertension?
    I don't have hypertenstion and my cholesterol is very low. I have been a vegetarian for years and I exercise regularly so I am somewhat fit even though I need to drop 60+ lbs. I was told that the stroke occured because I have stenosis/spondylosis and degenerative disc disease. I had several whiplash injuries with the worst being about 11 years ago. Apparently this set the degeneration in motion. The disc at C3-4 was protruding very far back toward my spinal cord and when I fell it momentarily compressed the anterior spinal artery. They tell me that this is what caused the cord stroke, and that I was VERY lucky because quite often this can lead to catastrophic injury

    If you have cervical spinal stenosis, the main reason for the pain is ischemia. For example, people who have arteriovenous malformations (which cause ischemia) develop pain, mainly because of ischemia.
    This is where I am confused. Is ischemia the lack of blood flow to an area, or the damage that is left after the blood flow is cut off? I was told that my neuropathic pain is due to the damage to my spinal cord caused by the cord stroke, and that the damage is probably permanent. I thought this damage was called ischemia. I have also been told I have myelopathy. Following the fusion/decompression my ns said the blood and CSF flow in and around my spinal cord is now good.

    You should ask your neurosurgeon about the hard lump. Sometimes it may be a stitch. It should be relatively easy to fix
    I had dissolving sutures. All of the sutures on the outside have dissolved. The lump spans the entire length of the incision so it must have something to do with what is going on in there. I am going to ask her about it when I see her on the 27th, but I thought you might know what is going on before then. Do the dissolving sutures dissolve faster on the outside than the inside?

    Regarding your hoarseness, to reach the C2-3 vertebrae, your neurosurgeon probably had to move your trachea to the side. This may have bruised the structures. They also must have intubated you. If the hoarseness does not go away, you should ask to see a laryngologist to take a look to see what is going on.
    She removed the disc at C3-4 and C4-5 and I was intubated. She feels the hoarseness was the result of the intubation but it seems like it should be better by now. I will ask about a laryngologist. I didn't know there was such a specialist. I am learning so much here.

    Where is the research and development in terms of the use of artificial discs rather than bone for disc replacement? I fear that the discs above and below the fusion will also deteriorate and need to be replaced at some point. What do they do when your entire neck needs to be fused? The thought of it scares the hell out of me.
    The next step would be a posterior decompression. Since you are already fused anteriorly, presumably at C2-3, a laminectomy at that level probably would not have much effect on the flexibility of your spine. Hopefully, if you take care with the other vertebra, you will not need to any more fusions.
    As I mentioned I am now fused at C3-4 and C4-5, so I guess that means C3 to C5. C4-5 was not as bad as C3-4, but it was on its way so she felt it would be best to take care of it now. I am starting to feel pain at the base of my neck now and I am very fearful about damage to the discs above and below the fusion since my ns said they will be taking the strain now. How do I prevent further damage? I have asked her about physical therapy but since the fusion seems to be going well she doesn't seem to think it will be necessary. How can I learn about caring for my neck and preventing damage and degeneration to the remaining discs and my spinal cord?

    Thank you so much.

    *Linda J*

  7. #7
    Hi, I'm just wondering whether your voice did come back? Did you end up seeing a laryngologist, and what did they say?

    Thanks!

  8. #8
    Giddy, the OP has not been on this site since 2005, so I suspect you will not get an answer to this question. Perhaps you could start another thread with questions here if you have a new injury, or on the Care forum if not.

    Also, please complete your profile.

    (KLD)

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