Instability Issues ???
 

Originally Posted by TomN
Hi Harrison,

Thanks for the welcome message!
I'm in a real bind. I have a relatively normal MRI with a bulge at C6/7 which was found after a car accident in December 2014. After 8 months of failed conservative treatments, I was told by a neurosurgeon (Penn Medicine) that I have Spinal Instability at C6 where C6 shifts backwards 5mm when my neck is in flexion. He said I need a fusion. My spine is being compressed at C6/7 which is why my hands and feet go numb when I look down. I then went back to LA to find a surgeon in LA to recover at home. I've seen several doctors who don't see the instability, including UCLA Spine.
Where would I find help on this site? Could you guide me and/or place this message to see if someone else had a similar problem?
Cheers,
Tom

Tom,

Sorry about your situation.

As I recall, this kind of spinal instability may be a contraindication for disc replacement (5 mm). You may find cowboys to do this, but that may be dangerous...

Pls search for the same term (or similar terms) and will find many posts on the subject. The search term is built into the navigation above.

You will see that most ADR mfrs. will disqualify you for disc replacement. There are many other types of spinal reconstruction, some even allow partial movement. Should you pursue this? Speaking for myself, I would not.

I know that hundreds of patients have done well with cervical fusion in this community. Yes, there have been complications from BMP fusions (especially cervical), but hopefully the lawyers and mfrs. have resolved these horrible complications with HO (heterotopic ossification).

Search and read topics -- going back 14 years:

- heterotopic ossification
- spinal instability
- BMP fusions or BMP
- etc.

Here's the search function:

https://www.adrsupport.org/forums/search.php

New info
 

Hey Harrison,

Yesterday I went to see the Dr that fused Peyton Manning's neck. He's a really good guy who took the time to answer all my questions and refer to my mri's to most of my questions. He told me to fuse my neck at C6/7 like he did on Peyton and how Peyton went back and played football..with a fused neck!

He said my neck is perfect except for C6/7. He said there is decent disc height loss, a decent bulge into the spinal cord sac, and bone spurs. I also have major narrowing of my foramin at that level which is why most of my pain and numbness is on my left arm. He didn't see any instability and did another flexion extension Xray and it showed no instability. I told him a doctor last month at Penn Medicine saw myelomalacia at C6/7. So he looked closely at the MRI and saw a white area that could possibly be this myelomalacia. That said, he's quite sure I have spinal irritation. I have L'Hermiites sign when I do a chin tuck. Then if I look down, my feet and pinky fingers go numb, still after 10 months following an accident. He said that would warrant fusion. But I spoke with Bertagnoli from Germany who said my films don't lead him to suggest spinal irritation at all. He said an ADR would not cause any aggravation of the spinal cord. And that I need surgery to stop the atrophy and open up the foramin.

The funny part of this whole day is that Watkins and Bertagnoli are friends. Watkins told me that Bertagnoli is the only guy that would put an ADR in a guy with spinal cord irritability. He said Bertagnoli is a little bit of a rebel in this sense. No one in the US would do it, as recommended by the FDA and the disc makers. So I'm totally stuck and confused once again.

I'm just going to ask you straight up as I'm just swirling in confusion and not that great at research.

With all your knowledge of who's had ADR on their neck, which docs have you seen higher numbers of success posts in this forum. Beirstadt, Bertagnoli, Clavel...a US doc?

I know I'm putting you on the spot but, maybe you can save me days and weeks of time.

Cheers
Tom

It took a very long time to come to this conclusion and it's subjective but, IMO it's Dr. Clavel. I suggest that you go to the Post Surgery Forum and search his name so you can read what others have said. I think it's important to know what you are getting into and to feel comfortable with your decision.

If you want to stay in the United States, I think it's the Texas Back Institute (Dr. Blumenthal) but, there is much less information in the forum compared to Dr. Clavel.

I spent about five months reading the forums and posts on this site. I also contacted all the surgeons you mentioned plus, Dr. Blumenthal at TBI and Dr. Zeegers in Europe. I sent packages to all but Dr. Bertagnoli. I am not a fan of the Pro-Disc nor, was I thrilled with the stories I read from patients that had surgery with him. I have a pretty extensive thread in the International Forum that may be helpful to you.

Good luck.

Tom, my two cents: get several opinions on what is causing the myelomalacia. Irritation is one thing, an undiagnosed condition is quite another.

E.g., if the blood supply is compromised to the cervical segment, which corrective option is best?! If bone growth is THE question post-op, which option is safest for the long term?

Sorry to say you have your work cut out for you. No pun intended. :look:

Many sources (web sites and doctors) say the same thing about myelomalacia:

"...The exact medical term means different things, depending on the reason why the condition exists. In virtually all cases, the condition involves bleeding within the actual spinal cord, due to trauma, disease process or other event..."

This should be re-written, for patients in your situation, to read:

"...The exact medical term means different things, depending on the reason why the condition exists. In virtually all cases, the condition involves bleeding within the actual spinal cord, due to trauma, AND/OR disease process AND/OR or other event.

These conditions are almost always multifactorial, IMHO.

Diagnosis
 

Thanks to both of you for responding with honest opinions.

I think I'm going to have to do the myelogram to know exactly what's going on. Dr Dillin at Kerlan Jobe said the dye will not lie. Ugh!

If there is pressure on the cord, the question then remains.

Will an ADR be OK with spinal irritation. Watkins says no but I'll bet all the Germans say yes.

And to top it off, I buried my dad last week. So glad I have a clear head?!

Thanks y'all

Tom: I wish you the best in your search for the right surgeon for you. You will know when you have found him.

Tom, I'm so sorry for your loss. My Mom passed in May so, I know what a difficult period this is for you. I was in extreme pain after my Mom died for quite some time. I believe the stress from grief really adds to our symptoms. Please don't rush into any decisions until you've had time to process some of your grief. It can be kind of a manic time so be kind to yourself. :(

myelomalacia
 

i am diagnosed with myelomalacia at C3-4, had an acdf 8 years ago, it is still there, however i don't have any bleeding. i have read this so many times in my records so i googled it and this is what i found; Myelomalacia is a pathological term referring to the softening of the spinal cord.[1] Hemorrhagic infarction (bleeding) of the spinal cord can occur as a sequel to acute injury, such as that caused by intervertebral disc extrusion (being forced or pressed out).[2]
The disorder causes flaccid paraplegia (impairment of motor function in lower extremities), total areflexia (below normal or absence of reflexes) of the pelvic limbs and anus, loss of deep pain perception caudal (toward the coccyx, or tail) to the site of spinal cord injury, muscular atrophy (wasting away of muscle tissue), depressed mental state, and respiratory difficulty due to intercostal (muscles that run between the ribs) and diaphragmatic paralysis.[3] Gradual cranial migration of the neurological deficits (problems relating to the nervous system), is known as ascending syndrome and is said to be a typical feature of diffuse myelomalacia. Although clinical signs of myelomalacia are observed within the onset (start) of paraplegia, sometimes they may become evident only in the post-operative period, or even days after the onset of paraplegia. Death from myelomalacia may occur as a result of respiratory paralysis when the ascending lesion (abnormal damaged tissue) reaches the motor nuclei of the phrenic nerves (nerves between the C3-C5 region of the spine) in the cervical (neck) region.[4] happy times huh? i haven't suffocated yet. best of luck to everybody.:) i may have it or edema and signal abnormalities at T8-9, T9-10 also

truly
 

Send you films to several surgeons. Get three or four assessment.

But truly if Dr. Clavel tells you that he would not do an adr in your case I would have fusion. As much as I hate to say that...

Pro-disc, not a huge fan either. The much bone milling. Mobi-C not constrained enough to protect facets; although better than fusion.

I will keep you in my thoughts:angel:....

Thank you Cheryl.
I will send my films to more surgeon over there for sure. What will haunt me is how Dr Watkins said fusion is the safest bet for irritability, and that ADR could quite very well leave me in pain as the cord will still hurt when bending at that segment. He even told me that Bertagnoli will suggest and ADR, and sure enough he did. And he said it will NOT affect the irritability of the spine at that segment. Ugh!

Sorry for your loss too. It certainly has sent my pain into orbit for a few weeks. I had a surgeon even tell me not to operate when you're grieving since there is a change in the chemical makeup of the spinal fluid while traumatized. So I'm waiting :)
I'm beyond confused as I haven't seen the myelmalacia on the films but a couple docs "think" they see it. Have you heard that it's a bad idea to do ADR with spinal irritability?

Hi Tom,

I contemplated adr vs fusion hard. Eventually went with adr. I did not experience full relief. I still have issues, which are likely caused by nerve irritation. Some spurs were left behind. This coupled with a lot of motion in my c6/7 is the likely cause of my problems. Everyone is different, but I should have fused. Now I am contemplating a revision to fusion.

So I think your surgeon may have a point. I would not rule out fusion yet. One level fusion is a successful operation in general. It will take out all possible pain generators in that segment. Proof of adr reducing adjacent segment disease in one level cases is not at all solid. Adr can be a viable option if you truly are a candidate. You see a lot of opponents of fusion on this board. But sometimes it is the better choice.

Those are my thoughts. I Am not saying you should not go with adr. But I would dig deep if there are any signs of contraindication.

Hi Simeoni, What was the "conservative treatment" that you mentioned in your previous post? Do you feel that it caused your frozen shoulder? If so, how? It's interesting that I'm seeing your post today for the first time. I'm saying that because I just came from seeing my physiatrist [physical rehab doctor] Dr. Ali Guy. I've known him for 25 years and he's helped me through some rough times. He told me that he has alot of patients who've had ADR and suggested I hold off and try a cervical epidural first. Though I'm not fond of being injected with corticosteroids I've had them a couple of times in the past for dance and athletic injuries and they did help [in some cases] for quite a while. Dr. Bertagnoli and Dr. Bierstedt both recommended a 2-level cervical ADR at C5/6 and C6/7 for me. Dr. Guy looked at my ex ray and said that if I only had ADR at C6/7 chances are I might be able to get away without requiring fusion, but that if I had both levels replaced that I would require a fusion because multiple ADRs without fusion have a high tendency to pop out. So, naturally, now that I've read your post, I'd be reluctant to have ADR at C6/7 without a fusion. Still have alot of thinking to do!
Thank you. Gabrielle

Hi Gabrielle. I do not blame the conservative treatment for my frozen shoulder. I am just saying it started during thar perioid before surgery. I had a couple steroid shots then. I consider my frozen shoulder as a body reaction to acute pain and c7 nerve disturbance. I have never heard anyone saying that adrs pop out in 2 adr constellation. I would question the implantation technique of such adrs.

In my case, all 3 surgeons I consulted have said that my continuing problems are likely caused bu the combination of remaining osteophytes and motion. If I had a fusion and such osteophytes, I should not have a problem. Adr motion en ironment is unforgiving to anything left behind.

Your case is a 2-level case. So the points to consider are different. Hope you find a good solution.

Diagnosis
 

Hey Simeoni,

I'm sorry to hear you are still having issues. Can you tell me a little about your journey with your symptoms. I feel very alone in my case as the cause of my symptoms has not been clearly identified on any MRI. And I'm wondering if we have similar circumstances. Did you have symptoms in your lower extremities? Did you have spinal irritability?

Best,
Tom

Tom, my story is long. I started having symptoms around 2002. They were constant since 2004. got really bad in 2010 and I had surgery in 2011. My pre-op symptoms have included leg pain and stiffness, also lower back ache. But the most pronounced symptom was right scapular pain and ultimately shoulder problems. Nobody could explain how my lower body symptoms could be caused by my neck, but they were reduced by surgery. I still have some occasionally, but mainly my problems now are in neck-shoulder-scapula area. Also headaches.

I do not know how spinal irritability is diagnosed or what it specifically is, but it is a good word for what I feel. My shoulder rom is still limited after 5 years since frozen shoulder onset. Frozen shoulder usually resolves in max. 2 years, so I have been suggested it is maintained by cervical problems. I cannot really move it to extremes of rom without irritating the cervical area.

Tyere is no quaranteed truth out there. Although I am sure my problems are originating from cervical, it is always possible there are other contributors. My case is not the usual and it is difficult to diagnose. CT shows a big osteophyte in c7 root foramen and it is supported by many of my symptoms.

Irritability
 

Hey Simeoni,

Your journey is definitely strange like mine. Doctors love to look at an MRI and hide behind the images and not want to dig any further.

My symptoms are constantly in my feet. Three docs think the cord is getting compressed at C6/7. I was told spinal irritability is when the cord keeps getting compressed by either the disc or the bone. The bruising of it will irritate it and many docs here agree that it's critical to stop the cord from bending where it's been bruised. Maybe that's what's happening with yours? Bertagnoli said that it's OK for the cord to bend at C6/7 while every single surgeon in the US says no way! Crazy. Don't know who to believe. All I know is my life is over until I get out of this brutal pain :(

Did you have instability?

Tom

Hi Tom,

My bending x-rays have never shown instability so I likely do not have it. Of course there is many kinds of instability, so who knows. I would be interesred to see your x-rays that show the presumed instability. If there is significant instability, then adr is quite clearly contraindicated. This is my impression based on a lot of reading. Please aknowledge that i do not have a medical degree.

Confused
 

Yeah, I've been told I have both instability and irritability, and haven't seen either one clearly on any MRI, with several doctors looking at them with me. I think I just haven't seen the right Dr. yet who knows exactly what's wrong and knows exactly what the fix is. I made an appt with a guy who comes highly recommended here in LA, Dr Khoo. He has an impressive background and helped my dad's friend when he couldn't get any answer from other doctors. Maybe he can shed light on my case and show me the problems on my MRI's.

I'm beyond frustrated and confused after 6 surgeons who have varying opinions regarding the reason my feet go numb when I look down.

Thanks Simeoni!
Hope you feel better!
Tom

Did you ask Dr. Clavel?

what they won't tell you though
 

Is how you most likely will develop adjacent level issues. That is instability too. Another reason why I like the M6; as it is more constrained than other ADR's. Things is you can always go to fusion later but not go from fusion to an ADR.

Cheryl, do you mean 1-level fusion will most likely lead to adjacent level issues? If you do, please back it up with some evidence? From what I know from years of reading and self-studying, this is quite an overstatement. Possible contra-indication of ADR is far more significant risk than fusion leading to ASD.

Clavel
 

No, I haven't asked Clavel yet.
Bertagnoli said there is nothing in my MRI that would suggest why my feet and both pinky fingers go numb when I look down. He said to do an ADR to fix the problem of foramina narrowing (2mm) and DDD with bone spurs at C6/7. But can't say whether the foot problem will go away. Ugh!

So now I've ben told I have spinal Instability and irritability but it can't be seen on any films. Anyone had this problem?

Tom, do the flexion extension x-rays show anything abnormal? Mri is in done in static neutral position and is not the best tool to pick up instability.

Flexion
 

Yeah
I did a flexion/extension MRI that said I had 5mm of subluxation then took it to 6 surgeons that said it wasn't there. Friggin crazy!!!!

Did a flexion ext X-ray a couple weeks ago and it also showed no instability. But I have all the symptoms of instability...Looking down and feet go numb along with pinky fingers.

Ask him. He provided the most accurate diagnosis for me, and I had asked 5 others as well.

Clavel
 

I will, thank you!!!
How are you feeling these days since he did your back?

re:
 

Recovery trully sucks. Still some LBP, but no sciatica.