Straight to Surgery?

[Timeoutofmind]

67 yo guy

Totally normal, reasonable, very high functioning professional.

Has been having left arm radicular pain for several months. Noticing some weakness in the last month or two. Hard to carry books, drooped a few things etc. On exam some subtle weakness of grip strength/hand on that side, but still like 4.5/5.

MRI below. I measured the AP canal diameter at that tightest level at around 9mm.

Has not done cervical traction/gabapentin or CESI.

Surgeon has him on for mid Decemeber for what sounds like a fusion. Said no point doing other stuff as surgery is going to have to happen.

What do you guys think? He is asking me if I would just have the surgery or try and hold off.

Seems like a tweener...

FINDINGS:
There is normal alignment without evidence of acute fracture or dislocation. Vertebral body heights are well maintained. Visualized cord is within normal limits. Normal marrow signal. Prevertebral soft tissues are unremarkable.

Individual disc levels are as follows:

C2-C3: Small posterior disc osteophyte complex and bilateral facet arthropathy resulting in mild spinal canal narrowing. There is mild bilateral neural foraminal narrowing.

C3-C4: Small posterior disc osteophyte complex with right lateral recess component and mild facet arthropathy resulting in mild to moderate spinal canal narrowing. There is moderate bilateral neural foraminal narrowing.

C4-C5: Small to moderate posterior disc osteophyte complex with right paracentral and lateral recess component resulting in moderate spinal canal narrowing and deformation of the ventral cord. There is moderate to severe right and mild left neural
foraminal narrowing.

C5-C6: Moderate posterior disc osteophyte complex and bilateral facet arthropathy resulting in severe spinal canal narrowing. There is severe right and moderate to severe left neural foraminal narrowing.

C6-C7: Moderate posterior disc osteophyte complex and bilateral facet arthropathy resulting in moderate to severe spinal canal narrowing. There is moderate to severe right and moderate left neural foraminal narrowing.

C7-T1: Mild disc desiccation without significant spinal canal or neural foraminal narrowing.

IMPRESSION:
Multilevel degenerative changes of the cervical spine as described, most pronounced at C5-C6 with severe spinal canal stenosis.

Neural foraminal stenosis as described.

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[SSdoc33]

67 yo guy

Totally normal, reasonable, very high functioning professional.

Has been having left arm radicular pain for several months. Noticing some weakness in the last month or two. Hard to carry books, drooped a few things etc. On exam some subtle weakness of grip strength/hand on that side, but still like 4.5/5.

MRI below. I measured the AP canal diameter at that tightest level at around 9mm.

Has not done cervical traction/gabapentin or CESI.

Surgeon has him on for mid Decemeber for what sounds like a fusion. Said no point doing other stuff as surgery is going to have to happen.

What do you guys think? He is asking me if I would just have the surgery or try and hold off.

Seems like a tweener...


View attachment 225014
View attachment 225015

he may need surgery, but not immediate. id give him a CESI and some PT first. i dont see a disc herniation or any significant NF stenosis, but i dont see all the cuts.

this is a case where an EMG may help if you know what you are doing

your manual muscle testing skills are more precise than mine. i usually can't narrow it down to the decimal level.

 

[Timeoutofmind]

he may need surgery, but not immediate. id give him a CESI and some PT first. i dont see a disc herniation or any significant NF stenosis, but i dont see all the cuts.

this is a case where an EMG may help if you know what you are doing

your manual muscle testing skills are more precise than mine. i usually can't narrow it down to the decimal level.

Edited my original post with the MRI report.

Thanks I should have included that

He does have a lot of foraminal stenosis

 

[lobelsteve]

Moderate foraminal on that slice, mild to moderate canal as well.
PT, CESI. No role for surgery. Likely same MRI 2 years prior. Unimpressive.

 

[Timeoutofmind]

Moderate foraminal on that slice, mild to moderate canal as well.
PT, CESI. No role for surgery. Likely same MRI 2 years prior. Unimpressive.

what about the weakness?
And the radiologist is calling it severe stenosis. (And I measure the canal at 9mm...)

 

[deleted185747]

0.5 grade muscle strength loss may be pain inhibition. If real weakness then >25% motor axons effected and will show up on needle EMG

 

[BobBarker]

It is mild to moderate stenosis. Avoid surgery. TENS unit and PT

 

[NOSfan]

Having trouble buttoning up buttons? Arm Reflexes diminished? Hoffman's signs? What dermatome?

--> GBP, PT, TFESI (Left C6 or C7) --> if no benefit then Surgery (?cervical foraminotomy if no abnormal movement on flex/ext).

 

[Timeoutofmind]

It is mild to moderate stenosis. Avoid surgery. TENS unit and PT

Why does everyone keep saying mild to moderate stenosis? The radiologist called it severe stenosis...There is no CSF at that level...The diameter is maybe 9 mm.
?

 

[BobBarker]

There is CSF on both sides in the sagittal cuts and there is no contouring of the cord at all.

 

[Timeoutofmind]

Having trouble buttoning up buttons? Arm Reflexes diminished? Hoffman's signs? What dermatome?

--> GBP, PT, TFESI (Left C6 or C7) --> if no benefit then Surgery (?cervical foraminotomy if no abnormal movement on flex/ext).

What is GBP?

 

[lobelsteve]

Gabapentin. AKA, gabatine in Geeorgia.

 

[clubdeac]

What level is your axial slice? C5-6? And yeah if he doesn't have any long track signs I wouldn't get too excited. In fact I see cervical spines like this all time here at the VA and the surgeon almost always wants to watch them. Then again he's not getting paid per surgery like your guy 😉

 

[Dr. Ice]

No signal in cord..not myelopathic..doesn't need decompression yet. I would treat with pt, nsaids, low volume cesi. Obvi discuss how cervical spondylitic myelopathy can present with stepwise neurological decline...

 

[drpainfree]

Gabapentin. AKA, gabatine in Geeorgia.

my patients, gabi

 

[Aether2000]

If the AP diameter is 9mm, it cannot be severe stenosis unless the cord itself is enlarged at that level- it does not appear to be. I agree with others that there is not severe central stenosis, and that this is an over-read or misread by the radiologist. The misinterpretation by the radiologist accompanied by some symptoms that may be attributable to foraminal stenosis may be prompting the surgeon to move (inappropriately) directly to surgery. However, there are not any other significant medical or alternative medicine techniques that will undo foraminal stenosis, so it is somewhat of a judgement call about when to pull the trigger.

 

[NJPAIN]

Gabapentin. AKA, gabatine in Geeorgia.

I thought that gabatine was french fries, gravy, cheese curds and gabapentin. Perhaps the definition is different in Canada.

 

[BobBarker]

Many of mine prefer neurotin in addition to their Lauratabs

 

[SSdoc33]

I thought that gabatine was french fries, gravy, cheese curds and gabapentin. Perhaps the definition is different in Canada.

poutine, i think

somewhere, ampa is itching to clarify the difference for us.

 

[NJPAIN]

It is poutine. I guess my comic delivery was faulty.

 

[Timeoutofmind]

If the AP diameter is 9mm, it cannot be severe stenosis unless the cord itself is enlarged at that level- it does not appear to be. I agree with others that there is not severe central stenosis, and that this is an over-read or misread by the radiologist. The misinterpretation by the radiologist accompanied by some symptoms that may be attributable to foraminal stenosis may be prompting the surgeon to move (inappropriately) directly to surgery. However, there are not any other significant medical or alternative medicine techniques that will undo foraminal stenosis, so it is somewhat of a judgement call about when to pull the trigger.

That is my thought as well

A tough situation.

Isnt the reality that this is unlikely to resolve with CESI/PT, etc because there is basically bony compression of the neural foramena?

And isnt it the case that delaying surgery just leads to a longer period of nerve injury, and a greater risk of permanent radicular issues post op despite decompression?

Especially given the little bit of weakness on exam, I am tempted to tell him to go ahead with the surgery

 

[Ducttape]

Poutine is like the Canadian version of chili cheese fries...

Gotta have real cheese curds and good gravy, and it can be amazing.

now it does not have to be just those 3. for example, breakfast poutine"

(images online courtesy of neighborhood poutine truck).

 

[lobelsteve]

That is my thought as well

A tough situation.

Isnt the reality that this is unlikely to resolve with CESI/PT, etc because there is basically bony compression of the neural foramena?

And isnt it the case that delaying surgery just leads to a longer period of nerve injury, and a greater risk of permanent radicular issues post op despite decompression?

Especially given the little bit of weakness on exam, I am tempted to tell him to go ahead with the surgery

No evidence of nerve injury. Something put him past the tipping point of symptoms. Do your job and knock him back asymptomatic and he won't consider surgery.

 

[pmrmd]

The right foramen looks worse than the left, but I can't enlarge the image. Canal is not that bad. He will improve with a CESI.

 

[clubdeac]

That is my thought as well

A tough situation.

Isnt the reality that this is unlikely to resolve with CESI/PT, etc because there is basically bony compression of the neural foramena?

And isnt it the case that delaying surgery just leads to a longer period of nerve injury, and a greater risk of permanent radicular issues post op despite decompression?

Especially given the little bit of weakness on exam, I am tempted to tell him to go ahead with the surgery

I've seen guys with far worse stenosis walking around with minimal if any symptoms. The nervous system is highly plastic and adaptable from what I understand

 

[emd123]

67 yo guy

Totally normal, reasonable, very high functioning professional.

Has been having left arm radicular pain for several months. Noticing some weakness in the last month or two. Hard to carry books, drooped a few things etc. On exam some subtle weakness of grip strength/hand on that side, but still like 4.5/5.

MRI below. I measured the AP canal diameter at that tightest level at around 9mm.

Has not done cervical traction/gabapentin or CESI.

Surgeon has him on for mid Decemeber for what sounds like a fusion. Said no point doing other stuff as surgery is going to have to happen.

What do you guys think? He is asking me if I would just have the surgery or try and hold off.

Seems like a tweener...


View attachment 225014
View attachment 225015

FINDINGS:
There is normal alignment without evidence of acute fracture or dislocation. Vertebral body heights are well maintained. Visualized cord is within normal limits. Normal marrow signal. Prevertebral soft tissues are unremarkable.

Individual disc levels are as follows:

C2-C3: Small posterior disc osteophyte complex and bilateral facet arthropathy resulting in mild spinal canal narrowing. There is mild bilateral neural foraminal narrowing.

C3-C4: Small posterior disc osteophyte complex with right lateral recess component and mild facet arthropathy resulting in mild to moderate spinal canal narrowing. There is moderate bilateral neural foraminal narrowing.

C4-C5: Small to moderate posterior disc osteophyte complex with right paracentral and lateral recess component resulting in moderate spinal canal narrowing and deformation of the ventral cord. There is moderate to severe right and mild left neural
foraminal narrowing.

C5-C6: Moderate posterior disc osteophyte complex and bilateral facet arthropathy resulting in severe spinal canal narrowing. There is severe right and moderate to severe left neural foraminal narrowing.

C6-C7: Moderate posterior disc osteophyte complex and bilateral facet arthropathy resulting in moderate to severe spinal canal narrowing. There is moderate to severe right and moderate left neural foraminal narrowing.

C7-T1: Mild disc desiccation without significant spinal canal or neural foraminal narrowing.

IMPRESSION:
Multilevel degenerative changes of the cervical spine as described, most pronounced at C5-C6 with severe spinal canal stenosis.

Neural foraminal stenosis as described.

Cord compression, cord changed or myelopathic signs and symptoms worry me more than which adjective (moderate vs moderate to severe vs severe) a particular radiologist attaches to an MRI report. A lot of it is patient dependent, also. While I think it's certainly reasonable to have this patient get a surgical opinion, especially with noted motor weakness, a lot depends on what the patient wants to do. If neither the surgeon nor the patient are hot on the idea of surgery, then it's reasonable to try CESI's. That being said, the motor symptoms concern me more than the MRI, and it sounds like your patient and the surgeon have agreed on going the surgical route. Option one, if the patient seems happy with the idea of a fusion and doesn't have much faith in trying injections, I don't usually push it. On the other hand, if their pain is significant, and if you've got a few weeks before surgery (as it sounds like you do) it wouldn't hurt to try a CESI or two in the interim and see what happens. They may not work and the patients gets the surgery. Or, you may get lucky and get more relief than expected and you may save the patient a surgery (for a while at least, probably not forever).

So much of this is subjective, especially since much of what we do surgically or with injections is elective. Therefore, patient preference is important. Some are surgery phobic. Others belief strongly in the knife and want a 'cure.' I usually explain the options, pro's and con's of each as I see them, and decide with the patient what to do, so long as it's a reasonable and justifiable course of action.

 

[DrCommonSense]

what about the weakness?
And the radiologist is calling it severe stenosis. (And I measure the canal at 9mm...)

Weakness is the critical component of the situation.

An EMG/NCS can be helpful to determine the extent of actual physical damage being developed from this stenosis.

If there is no weakness/muscle atrophy, I see no point in rushing to surgery. Older patients can live with this condition until they die with just conservative treatment (PT, CESI, Gabapentin) if it doesn't progress further, which they often don't.

 

[DrCommonSense]

If the AP diameter is 9mm, it cannot be severe stenosis unless the cord itself is enlarged at that level- it does not appear to be. I agree with others that there is not severe central stenosis, and that this is an over-read or misread by the radiologist. The misinterpretation by the radiologist accompanied by some symptoms that may be attributable to foraminal stenosis may be prompting the surgeon to move (inappropriately) directly to surgery. However, there are not any other significant medical or alternative medicine techniques that will undo foraminal stenosis, so it is somewhat of a judgement call about when to pull the trigger.

A cervical fusion doesn't actually undo cervical stenosis without adding other problems though.

Fusing the spine leads to major mechanical problems down the road, so its basically substituting one problem for another.

Why treat something surgical that can be managed conservatively as long as possible? Many patient's stenosis doesn't progress further.

 

[Orin]

It's a RBO issue here.

I counsel patients to pursue conservative treatments first but refer them to a surgeon who isn't aggressive for a discussion, although foraminal stenosis is a different animal than canal stenosis as I think most would operate more aggressively on that.

Age is an important variable as I'd rather someone get their spine operated on at 65 than 75 or 85, especially if they have other comorbidities that are not going to age well.

I'm not confident we have good literature on the progression of spinal stenosis, the impact of conservative therapy on progression, and where the inflection point is for that risk/benefit curve.

I am pretty confident that epidural steroids aren't going to fix the radiographic findings in this scenario, though they may help pain, and are going to add to that buffalo hump.

 

[Ducttape]

I fortunately work where most if not all the surgeons are quite conservative.

Did the surgeon document weakness?

The patient needs to make a choice. If pain is the primary issue, conservative treatments are in order.

If the patients perception of weakness is his primary (and secondary) concern, then I can see surgical options as main treatment (after PT and the like).

 

[SSdoc33]

I fortunately work where most if not all the surgeons are quite conservative.

Did the surgeon document weakness?

The patient needs to make a choice. If pain is the primary issue, conservative treatments are in order.

If the patients perception of weakness is his primary (and secondary) concern, then I can see surgical options as main treatment (after PT and the like).

surgery wont make him stronger.

will is prevent the progression of weakness? hard to say. maybe

 

[SSdoc33]

It's a RBO issue here.

I counsel patients to pursue conservative treatments first but refer them to a surgeon who isn't aggressive for a discussion, although foraminal stenosis is a different animal than canal stenosis as I think most would operate more aggressively on that.

Age is an important variable as I'd rather someone get their spine operated on at 65 than 75 or 85, especially if they have other comorbidities that are not going to age well.

I'm not confident we have good literature on the progression of spinal stenosis, the impact of conservative therapy on progression, and where the inflection point is for that risk/benefit curve.

I am pretty confident that epidural steroids aren't going to fix the radiographic findings in this scenario, though they may help pain, and are going to add to that buffalo hump.

for LUMBAR stenosis, 70% stay the same, 15% improve, 15% get worse. now, we may quibble with the study itself, but you can use this as a starting point

Johnsson KE, Rosen I, Uden A. The natural course of lumbar spinal stenosis. Clin Orthop;279:82–86, 1992.