New Here, need some answers guys

[SandyW]

Mark, I moved this from another site to my post asking for help.

I am sooo confused. Dr. Fenk-Mayer recommended 3 cervical replacement discs - no discogram on C4-7. However she informed me that I might need a 4th so would do a discogram prior to surgery on C3-4 only. I had no pain because the dye went in and out, no pressure, no pain nada. Why are you saying that the test is painful? Was C3-4 ruptured? not buldging? The other disc's were making a dent in my spinal cord, that's why I thought surgery was recommended. I posted earlier that I need some questions answered, so if you all have time I'd love to hear from you. Sandy

Your answer Mark:

If there are obvious structural problems at 3 levels, especially with spinal cord involvement, then there is no need to do discography on them. There is no "take it or leave it" decision to be made... they are going even if they are not painful. However, you can have these structural issues that need to be addressed, and they may not be your pain generators. If there is a disc next to the obviously needing replacement levels that is bad, discography there will keep them from leaving a disc that is causing substantial symptoms.

Ok, I understand why they didn't bother doing a disco on C4-7, had not choice there. And I read your post on your discogram. But what does it mean when the fluid runs in an out of your disc, my C3-4. Why was that level replaced?, it didn't hurt. I too was dreading this, in fact I asked Dr. FM if they would just go ahead and do the 4 and forget the discogram. LOL I trust that I needed the 4 levels, am not questioning this, just would like to know what was wrong with that disc. Don't know why I didn't ask questions then when I was surrounded by experts!

My pain pre-op was less than my pain now. I'm 9 months post-op, am taking tramadol, zanaflex, tylenol and ativan at bedtime. This combination doesn't get rid of the pain, doesn't make me sleepy, don't sleep well at night. I'm concerned, that's why I'm asking questions. There are so many people still in pain, that have tried so many things, it's mind boggleing. Thought if I understood my MRI it was a place to start.

Even though I'm not disappointed in my 4 prodisc-C's, I don't think there is a better surgeon for mulitples than Dr. Bertagnoli and I don't think I would have fewer difficulties with fusion AND I'm still mobile. I wanna be pain free!!!

Not being able to find a doctor here who will see me is difficult - guess surgeons don't like to do follow up, unless they do the surgery. I finally ask Dr. B to call Dr. McLain at the Cleveland Clinic (who I have seen multiple times prior to surgery) and that worked. I have an appointment on the 22nd. Hopefully between a spine doctor and their pain management department, I'll get some answers. I would like to ask intelligent questions, I've never felt so overwhelmed. Anything has to be better than my poor family doctor who tries to help, but isn't well-informed concerning ADR's.

Mark, wow didn't know you were having more surgery - cervical now. You two make a good pair! Was surprised to hear all your concerns since you see so many surgeries. Always more difficult when it's YOU. When is surgery scheduled? You aren't going to be with a patient too, are you?

You will be in our thoughts and prayers, Sandy

[mmglobal]

You didn't copy the "I'm not a doctor" qualifiers... please take everything I say with a grain of salt.

Discography has many different ways to show pathology. The pain we are trying to generate by pressurizing the disc can only be generated if the disc will hold pressure. If there is a substantial annular tear so the contrast just runs out, then the opportunity to generate the "pressure" pain is not present. However, they can see the pathology... they can see the contrast immediately run through degenerated-looking tissues, through the tear and into the canal area.

With such an annular tear, it's possible that the level is painful due to chemical irritation of the spinal cord or exiting nerve roots. They can't be certain. It's a crap shoot... more levels? risk leaving a pain generator? I've seen the decision go both ways and it depends on the intuition of the doctor.

It's also possible that your pain is not coming from the ADR's or those levels, but from the surrounding musculature. I don't think that pain free is a reasonable expectation after a 4-level surgery. Some get it, but they are lucky. Sorry, but I'm not a sugar coat it kind of guy. We certainly don't expect things to get worse. Hopefully you'll experience substantial improvement as your body gets used to your new alignment.

All the best,

Mark

[SandyW]

Mark,

Sorry about not copying "I'm not a doctor" qualifiers. I would never take the advice as though it is coming from a doctor, but do like to hear from people who have experienced/witnessed the same. Am beginning to understand AND you are cheaper, easier to reach, and quicker getting answers from - that what's so great about the site. Thank you.

Don't like what you're saying about 4 levels, but sort of thought that the case. Just want you to know I'm going to be one of the lucky ones. I'm a fighter, just not patient.

Sandy (thanks for fixing my name)

[Justin]

Hey Sandy,

I'll have a read through your post later today...I'm running around like a mad man now...

I didn't want to leave you hanging.

[Terry Allen Blackburn]

Sandy:

I hate to say this but your age may be a factor in what you are experiencing. If I remember correctly, you have some mitigating things medically, at your age, that will interfere with the healing process. The other thing is that you surgery is still less than one year ago. It took me all of twenty months to feel Top Shelf after my four level ADR surgery. It was definitely a roller coaster ride. You might want to check with a physician about the possibility to get injections done in your spine to help alleviate some pain. I had facet injections and SI joint injections every three months after my ADR surgery which brought me considerable relief. These never worked prior to the surgery as I was so badly damaged. After the surgery, while I was healing, the injections worked just fine but, took a few weeks to start working after I received them each time. I went for a whole year without any but went through a bad patch before Christmas time. I was able to get SI joint injections and I am back to being much better. I was also on Lyrica for a year and a half after the ADR surgery, at about 400 Mg. This helped immensely with the nerve pain. I still think you need to give yourself proper time to heal.

Also, please check out the possibility of some injections.

Hang in there.

Terry Newton

[Justin]

Sandy, my replies are in bolded text...

Originally Posted by SandyW

Now, I don't understand my MRI from 12/2007. Didn't ask enough questions, knew I didn't want fusion. Am going to see spine doctor at Cleveland Clinic finally for a much needed follow-up (Dr. B had to refer me) and want to be able to ask some intelligent questions. Looked up terms, got some thoughts from other site, but need the explanation from the "experts."

"There is some mild straightening of the normal cervical lordosis without focal subluxation. Overall spinal canal diameter is somewhat small, suggesting an element of congenital stenosis.

There is generalized multilevel disc desiccation and degeneration, mainly involving C3-4 through C6-7.

At the C2-3 level, no focal disc protrusion.(Had a discogram in Germany prior to surgery, no pain whatsoever, Dr. FM said dye went in and out, could the procedure have caused the disc to rupture? Decision made to do 4 adr's instead of 3.) There is some mild left-sided degenerative foraminal stenosis.

Sandy, no expert here. I'll help answer your questions: in my opinion, I don't believe the procedure caused the disc to rupture. As you are aware, a needle is slowly inserted into the disc in which contrast is injected during a discogram. This causes an increase in pressure in the disc (chemical irritation, etc. etc.) resulting in pain.

Your discs are similar to "pin cushions." This is a really poor example, but it's an easy one..the annulus fibrosis is the outermost portion of each disc, in which fibers are wrapped around each other many times (picture a wicker basket) and the center of the disc is the nucleus pulposus--it's similar to a jelly-like substance that is held in place by the annulus fibrosis that encircles it. During the discogram, when the needle is inserted into the disc it "pokes" through/around the annulus fibrosis fibers. IMHO, this would not result in an annular tear, especially since the technique of discography has been greatly improved over the years. (This is not to say it has never happened in the past.) Also, the size of the needle (or gauge) that is used is very small.

With the dye "going in and out" like you describe, it sounds like the tear in this disc was pretty big. This means your disc was unable to "hold" any pressure from the injection. A smaller tear would be able to hold more pressure/dye and in theory less dye would leak from the disc at a slower rate. However, this varies depending on the grade (size and location) of the tear.

I notice it states "At level C2-C3, no focal disc protrusion." This is why discography is done--discography is not used to look for herniations per se, but it is used to look at what is termed "internal disc disruption." This means it is looking for tears that are not easily visualized on xrays or an MRI.

If you took 10 people off the street at random and gave each person an MRI, most of these patients would have some degree of protrusion (herniations) / cysts that are asymptomatic. Thus, not all protrusions are problematic -- especially as we age.

I hope this makes sense...

At the C3-4 level, there are endplate osteophytes and some degenerative changes in the facets. The sac measures 9 or 10 mm in AP dimensions. (What is AP and what does 8, 9, 10 mm dimensions mean?) There is asymmetric osteophytic foraminal narrowing more on the left.

AP is anterior posterior: this describes the way “the picture” passes through your body – here it is going “in” your neck (front) and then “out” (back) of your neck. Anyway from the literature I have read, stenosis is defined as AP dimensions of less than 10 millimeters.

At the C4-5 level, there are endplate osteophytes. There is indentation on the anterior aspect of the sac which measure 9 or 10 mm in AP dimensions. There is some osteophytic foraminal narrowing, greater on the left.

At the C5-6 level, there are endplate osteophytes. There is indentation on the anterior aspect of the sac, which measure about 8mm in AP dimensions. There is asymmetric osteophytic foraminal narrowing, greater on the left.

At the C6-7 level, there are endplate osteophytes indenting the anterior aspect of the sac, which measures about 9mm in AP dimensions. Exit foramina are only slightly distorted.

At the C7-T1 level, no major abnormality." (was there anything in MRI that said adr?, I didn't ask, just took advice, fusion or replacement, although film showed disc's making indentations on spinal cord, anything that might suggest why I have more pain now than pre-op? Not sorry I had adr's, couldn't stand the thought of fusion, but am wondering why the pain)

Sandy, there was no mention of ADR on the MRI. The MRI usually only reports on how your cervical spine and surrounding structures “look.” Based on this MRI, then your surgeon(s) decide what the next step in treatment is based on these films, other tests, your medical history, etc... It does sound like there was some compression of your spinal cord before surgery (so it sounds like you had issues that needed to be addressed one way or another—I’m going out on a limb here, as I don’t have your films in front of me).

There could be a whole host of reasons for continued pain. It gets tricky, as you know…I’m still trying to work up why I have constant bilateral leg pain after 4.5 years of pain-free life post-ADR.

I wish you the best and I hoped this helps…keep us posted.

[Maria]

Hi Sandy,
Nothing to add except welcome to this site and hope you find some answers you are seeking no matter what course of action that is taken (invasive, non invasive, combination).