Clinical Key Points:
This patient suffered with disabling neck and right arm pain, a misleading MRI scan & demonstrates our cautious approach & the ability to operate on targeted discs as their role in symptom production becomes clearer.
History & Prior Treatment:
Susan presented to the Spinal Foundation in November 2008 and informed me that she developed back and neck pain 12 years ago after a road traffic accident. On 1 May 2008 she developed stabbing pain in the back of her neck and in her right arm with pins and needles in the right hand. On November 6, 2008 she was hanging out her washing and developed stabbing pain in the right shoulder and neck and was admitted to hospital for 10 days without benefit.
Her sitting and reading duration was 15 minutes & her walking distance 50 yards with a restart time of 5 minutes and a post activity penalty of 15minutes.
These symptoms impaired gardening, dancing, household chores such that she had to employ a cleaner. Prior treatment had consisted of physiotherapy, injections and significant combinations of pain modifying drugs to little or no avail.
Distribution of Symptoms
80% of her symptoms reside in her neck , right Trapezius and shoulder. Her pain manikin reveals aching in the suboccipital region with aching and stabbing at the cervico- thoracic junction which radiated to the right scapular with aching over the posterior aspect of the right shoulder and numbness and burning radiating through the anterior aspect of the right shoulder upper arm and forearm with pins and needles in the palmar aspect of her right hand.
Weight bearing X-rays revealed a balanced T1. Right C6/7 intradiscal tilt. C3/4 left intradiscal tilt. C2/3 anterior Olisthesis worsening in flexion and correcting in extension. C3/4 posterior osteophytosis. C5/6 diminished disc height with anterior Olisthesis and hypomobility.
MRI scans, 05.12.07 revealed wide spread degenerative changes affecting all vertebral segments. No focal abnormality seen in the spinal cord. The cervical spine cord otherwise normal. On the axial scan: C2/3 the left exit foramen is mildly narrowed, C3/4, C4/5, C5/6 and C6/7 – Normal appearances.
Conclusion: Widespread degenerative change affecting all vertebral segments. No focal lesion in the spinal cord. Mild narrowing of C2/3 left exit foramen.
The MRI Scan of 10.11.08 revealed on the Sagittal T1 and T2 weighted sequences that the neck was held with a normal gentle lordosis and the cervical canal is a reasonable size at all levels. There is minimal bulging of several of the cervical discs but these do not come into contact with the cervical cord which itself appears normal at all levels.
Review of the axial images shows generally rather small bony neural foraminae. However, there is definite bony encroachment only at the C5/6 level involving the left C6 neural foramen.
She had a numb lateral border of the left foot with hypersensitivity in the distal L5 distribution and the left foot was swollen. The left knee jerk was absent, the left ankle jerk diminished but the power was normal.
Minimally Invasive Spinal Surgery: - December 2009
Right C5/6 Spinal Probing and Discography and Laser Disc Decompression.
Discography produced posterior neck pain, right shoulder pain right “numb like” discomfort down to the elbow. Full AP and lateral degeneration was noted together with hanging drapes, a 20% bulge and a left foraminal collection. In the light of the production of all her symptoms concordantly, discography was not performed at C6/7 so as to minimise risk.
C5/6 was treated with a Laser Disc Decompression using 500J 20/20. During this procedure neck, right shoulder and proximal arm pain was reproduced. 10 mls of saline washout was effected. 80 mgs of Depomedrone and 80 mgs of Gentamycin were instilled and the wound closed with one suture.
6 weeks following the intervention, Susan felt that the operation was a success as she was pain free. However she did have some residual numbness below the right elbow on the ulnar border which was also improving. She had some residual pins and needles into all her right fingers, the frequency of which was staying the same.
4 months post intervention the symptoms of pain and numbness in the neck and the right trapezius, shoulder and upper arm have been relieved & the previous agony has not recurred. She is taking Emflex and Paracetamol and is off Gabapentin and Morphine.
But she is still experiencing numbness and a heavy feeling below the elbow along the radial border of forearm and all fingers with the exception of the thumb. After further discussion she is considering Minimally Invasive Spine Surgery at the C6/7 level.