C7

Persistent pain after a cervical fusion

Here’s an interesting case of persistent pain after a cervical fusion

I recently had the opportunity to evaluate and operate on a really interesting case.  This is a man in his late 40’s who had an anterior cervical discectomy and fusion 2 and 1/2 years ago.  Prior to his operation, he had really severe right sided C7 pain.  After his operation, even though it was done by an experienced surgeon and appeared to be done well, his pain persisted.  Prior to coming to see me, he picked out this image on his pain diagram.

In my office, it was clear that he was really suffering from a C7 radiculopathy.  He had pain all the way down his right arm to the back of his hand.  He couldn’t sleep at night, and he was basically stuck on pain pills.  I really carefully reviewed his CT scan that was obtained after his fusion, and here is what I saw….

The surgical decision making process

We had a really long discussion.  We talked over all of the options that he had for treating his pain, and ultimately we decided to go ahead with a cervical microforaminotomy.  This is an operation that I really like.  I’ve done many of them in the past 5 years and I feel like it is an operation that is not used as often as it should be.  I have a blog post on my philosophy of why cervical microforaminotomies work really well.

cervical microforaminotomy versus anterior cervical discectomy and fusion

In this case, it was the perfect operation for him.  He woke up without the same nerve pain he had been living with for years.

hands with arthritis

How do you know if you have spinal stenosis?

What is spinal stenosis?

Spinal stenosis is a medical condition where the space available for the spinal cord and nerve root is narrowed.  This narrowing is caused by disc herniations, disc bulges, and arthritis of the spine.  Enlargement of the facet joints, caused by wear and tear, is a common cause of stenosis.  If you think back to your grandmother’s hands, you’ll remember that her knuckles are large and bony.  This process is caused by bone spurs that grow around the edge of a joint that is starting to wear out.

spinal stenosis is caused by arthritis

The same process occurs in the lumbar spine.  The facet joints on either side of the spine become enlarged with time and they trap the nerve roots in an area called the lateral recess.  A bulging disc pushing on the nerve from the other side usually makes the pain intolerable.

How does spinal stenosis develop?

Spinal stenosis develops very slowly over time.  The most common cause of stenosis is BIRTHDAYS!   The more birthdays you have, the more like you are to develop arthritis of the spine and stenosis.  Since everyone who lives long enough will develop some degree of stenosis, the question is, when do you know if spinal stenosis is causing your buttock and leg pain.

What does spinal stenosis look like on an MRI scan?

Here is a short video where I describe the findings of stenosis of the spine at two levels.

The 4 questions that will tell us if you have spinal stenosis

A recent study was published in the medical literature which asked medical experts from all over the globe how they knew if someone had spinal stenosis.  It comes down to four simple questions.  The answer to these four  questions can tell us if you are likely to have symptomatic stenosis.

1.  Do you have leg or BUTTOCK PAIN while walking?
2.  Do you FLEX FORWARD to relieve symptoms?
3.  Do you FEEL BETTER if you can LEAN on a shopping care while walking?
4.  Do your legs feel WEAK or NUMB while you are walking?

The scientific consensus on the symptoms of spinal stenosis

The reference for this paper is as follows:

1. Spine (Phila Pa 1976). 2016 Aug 1;41(15):1239-46.  ISSLS Prize Winner: Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis: Results of an International Delphi Study.

Minimally Invasive Surgery for Spinal Stenosis

I specialize in microscopic decompression surgery of the spine.  If you’ve already had an MRI scan and are interested in discussing your options, I will review your MRI scan for and tell you whether or not I think a microscopic decompression can improve your symptoms.

To learn more about your options for, click here:

[button url=”www.sohrabgolloglymd.com/upload-mri” target=”_blank” color=”blue” size=”medium” border=”false” icon=””]MRI Review[/button]

MRI annular tear

Why do annular tears hurt so much?

Annular tears are seen on MRI scans of the lumbar spine.  They appear as tiny white dots in the back of the disk.  The radiologist will call annular tears “posterior high intensity zone lesions.”  In addition to severe low back pain, they are a source of confusion, concern, and unanswered questions about their significance and treatment.

Here is a short video where I review the MRI scan of someone with an annular tear of the L5-S1 disc

Here is a short description of his symptoms in his own words:

  • prior to August 2016 I was doing a lot of recreational running

  • At the end of July 2016 I fell while biking, felt a sharp pain immediate after fall but everything seemed OK after two days.

  • early Dec 2016, moved a piece of furniture and felt sharp pain in back – obviously this caused severe injury of the disc

  • mid Dec 2016 – got my MRI scan

  • end Dec 2016 – new sharp pain bottom of pelvis. Obviously I re-injured the disk again and made things worse. Back pain lasted for 2-3 weeks before slowly improving.

  • Jan 2017 – back pain started to improve and I was able to do some back pain excercises

  • beginning Feb 2017 – started to feel numbness (I assume it was because I took a business trip, more sitting, traveling with bag, airports… that caused things worse)

  • last 7 days I was very careful and things have improved slowly.  my tensor latae fasciae spasm continues.  I cannot run.

  • Through all this time I felt almost no leg pain. I had some occasional pain in the toes which I was not sure if originates from spine (not severe, one day episodes). Numbness scared me but it was not very severe.

What I ask myself all the time is:

  • I can hear popping in my back with certain moves (for example changing position while sleeping from one hip to another or with some leg movements). Does this come from the disc tear or herniation? It is painless.  I have feeling it comes from the back.

  • What is my prognosis? As most people would, I would like to avoid surgery but do not want to make things worse. I have no problems with pain at the moment but would like to return to some sport activities in the future. I learned that healing should take at least 6 months. Is this possible without surgery in my case?

  • What would be your recommendation in my case?

And here is his MRI scan

In this patient’s case, I recommend that he continue with non-operative care.  His pain has already started to decrease and he is still active.  We would reasonably expect that with time this should heald and he should feel like he has a normal spine.

Here are some other examples of MRI scans of the spine with an annular tear

In this first example of an annular tear in the L4-5 disk in a 22 year old female, there is a tiny white dot in the back of the disk where the fibers of the annulus are torn.

annular tear L4.5

In this second example, in the L5/S1 disk, the annular tear is centrally located and is more apparent on the axial view.  These are T2 sequences, and the computer algorithm that creates the T2 images from the raw MRI scan data makes fluid look bright white.  You will notice that the cerebrospinal fluid appears bright white.  CSF is a filtrate of plasma.  Since the CSF appears white, we conclude that the annular tear is probably a gap in the fibers of the annulus fibrosis that is fluid filled.

Most patients with annular tears have similar histories.  They report that they were lifting a heavy object, moving awkwardly, or twisting at the same time.  Suddenly they felt like they were shot or stabbed in the back.  They are often in a tremendous amount of pain.  Since they do not have a large disk herniation on the MRI scan, these patients are often described as having “pain out of proportion to expectations”.  This is a little unfair because in my experience, annular tears seem to be very slow to heal and they can be a cause of long lasting and disabling back pain.

Why?

I believe that annular tears represent a partial disk herniation.  The annulus fibrosis that surrounds the intervertebral disk is made up of many layers.  When an annular tear occurs, the central portion of the disk, the nucleus pulposus, herniates through most, but not all of the layers of the annulus.  A fragment of disk material is stuck in the middle of the tear and it is surrounded by fluid and inflammation.

The nucleus of the intervertebral disk is made of a protein core consisting of proteoglycans.  These long, branched proteins are relatively acidic, viscous, and naturally slippery.  As such, they are designed to prevent adhesions and scar tissue formation since they are natural shock absorbers.  When they get trapped in between the fibers of the annulus, they prevent the collagen fibers in the annulus from healing.  As a result, there is a permanent weak spot in the fibers of the annulus which is a constant source of pain.

Whats the best treatment for annular tears?

A number of times in my surgical career I have operated on patients with broad based disk bulges, an annular tear, and both back and leg pain.  When I make a small incision in the outer covering of the disk, a fragment of disk material squeezes out as if it were under pressure.  Typically, there is a small cavity where the annular tear is located that is filled with fragments of disk material.  The patient’s leg pain gets better after the operation because of the microsurgical decompression.  Interestingly, the patient’s back pain improves rapidly after the operation because without the fragment of the disk stuck in the tear the annulus can finally heal.

I’ve arrived at the conclusion that for some patients with relentless back pain related to an annular tear it makes more sense to have a microsurgical decompression with an exploration of the annular tear and a removal of the fragment of the disk that is just underneath the surface.  This seems to kick start the healing process and let them get on with their lives faster. My favorite technique for treating annular tears is now an endoscopic technique. Here is a video of how I do that operation:

Other patients, however, will get better with non-operative treatment.  With time, and and a gradual return to normal activities, their back starts to settle down and they have less and less pain.

The other option is an injection into the disk space of either platelet rich plasma or adipose derived stem cells.  There is good evidence to suggest that PRP injections are effective in shortening the time that annular tears hurt.  Stem cell injections are also a really exciting area of active clinical research and there is some early evidence to suggest that stem cells injected directly into the disc may help.  At the moment, the best evidence suggests that either a microscopic decompression with a removal of the trapped fragments or a platelet rich plasma injection is the best treatment if non operative treatment simply isn’t working.

What kind of options do you have if you have an annular tear?

Many annular tears will get better with non operative treatment, but some don’t.  If you’ve had pain for more then 6 weeks and you have already had an MRI scan of the spine, I can review your MRI scan for you and tell you what options you have.   To get started with this process click here: MRI review service

reverse hyper

Spondylolisthesis: can it be reversed?

What is spondylolisthesis?

Spondylolisthesis is a common cause of back and leg pain.  The most common question that I get asked immediately after I tell someone that they have a “spondy”, is a variation of….

  • “Can it be fixed without surgery?”
  • “Will it go back into place if I do a lot of back bends?”
  • “Can I reverse my spondylolisthesis with physical therapy?”

Let’s look deeper into questions surrounding the idea of reversing spondylolisthesis.  The word spondylolisthesis has two words with Latin roots.  “Spondy” is latin for spine, and “listhesis” is latin for slipping.  In this condition one vertebral body slips forward with respect to the one immediately underneath it.  The two most common locations of a spondylolisthesis are L4-5 and L5-S1.

Case Examples

Here is an X-ray of the spine with a spondylolisthesis at the L4-5 level.  In this case, this a grade 1 slip — L4 has slipped about 20% of the length of the L5 vertebral body.

 

L4.5 grade 1 spondy lateral preop

This condition has a couple of different causes.  The most common cause of a spondylolisthesis is degenerative disk disease caused by the normal aging process.

The other most common cause is repeated hyperextension during sports as an adolescent when the spine can develop a stress fracture called a “spondylolysis”.  This typically causes back pain during adolescence and may later progress to a spondylolisthesis.

Why do some people develop a spondylolisthesis?

The risk factors for developing a spondylolisthesis include:

  • female sex
  • hyper flexibility
  • increased lumbar lordosis
  • according to Readysteadygymnastics.co.uk, sports such as football and gymnastics that involve hyperextensions of the spine.

I’ve written a more detailed article about there natural history and treatment of spondylolisthesis here: https://sohrabgolloglymd.com/spondylolisthesis/

Reversing Spondylolisthesis: is it possible?

Since the surgical treatment for fixing a spondylolisthesis typically involves a single level fusion of the spine, most people want to know about their alternatives.  Their two most common concerns / desires are as follows:

1. They are reluctant to jump right into a fusion

2. They are very interested in alternatives.

I’m a cross fitter.  I love to surf.  If I had a spondy, I’d want to wait for as long as I could before I got a fusion.  I’d also do all the PT and non-operative treatment that I could.  I checked the crossfit boards and found this thread on spondylolisthesis:

“I am an active duty Army officer diagnosed with Spondylolisthesis, L5 shifted approx 30-35% forward (anterior) over S1. I most likely incurred my injury during my early years in the military. To my knowledge, the degree of shift has not changed over the years. I have been crossfitting for 4 years, and my back issues have fluctuated over the years in terms of severity and impact to my workouts. However, it has not impacted my ability to do my job or deploy. At this time, I am mid way through my 8th deployment, and I’m trying to proactively minimze my syptoms as much as possible on a daily basis.

I avoid heavy deadlifts and GHDs, but pretty much do every thing else as Rx’d. My symptoms sometimes include back soreness, which gets too severe to exercise about 1-2 times a year for a few days. I do my best to listen to my body and reduce my activity when this happens.”

The recommendations that follow this post include an excellent discussion about the pros and cons of reverse hyper-extension exercises with the lumbar spine, inversion therapy, and avoiding certain heavy lifts — like deadlift and squats.  If you want to read the entire thread, follow this link — http://board.crossfit.com/showthread.php?t=61980

This is a picture of rogue’s reverse hyper extension machine for the lumbar spine:

reversing spondylolisthesis

http://www.roguefitness.com/rogue-reverse-hyper-2

What should you do next?

Here’s my opinion.  FORM is critically important if you have a spondylolisthesis.  If you think about it, a spondylolisthesis is probably a normal response to an abnormal movement pattern.  Most of these patients trend towards the hyper flexible part of the athletic spectrum.  Their joint laxity and movement patterns probably put increased stress on the intervertebral disk during physical exercise.  Most likely, this is a shear type of force where the trunk is trying to slide anteriorly with respect to the pelvis.  If the core is strong and the trunk is solidly anchored to the pelvis, this shear force should be offset by the stabilizing strength of the glutes and spina erecta musculature.

If you workout with PERFECT FORM, you should theoretically neutralize the forces trying to push your slipping vertebral body anteriorly.  If you strengthen the muscles that neutralize these forces, you should be able to work out with risking progression while also stabilizing your core.   Do this for long enough and you’ll have a bullet proof core and less pain.

My favorite book on this subject is Kelly Starrett’s Becoming a Supple Leopard, but you can always start with https://www.mobilitywod.com.

Neutral Spine.  Neutral Spine.  Neutral Spine.  That’s the mantra you should be repeating to yourself every time you lace up your shoes if you have a spondylolisthesis.

What about surgery?

Finally, a word about surgical treatment.  As the field of microscopic spine surgery has evolved, I have become much more willing to perform an microscopic decompression of the nerve roots affected by the spondylolisthesis, especially if someone has leg pain on only one side.

In my opinion, correct body mechanics has just as much ability to stabilize a spondylolisthesis as a fusion does, and if I needed an operation because I had relentless leg pain due to a spongy, I’d have a microscopic decompression and be absolutely meticulous about my rehab.

If you’ve got questions about what to do about your spondylolisthesis and you’d like us to review your MRI scan, we’d be happy to just visit this page here to get started.

back-pain-and-strength-training

Back pain and strength training…. are free weights an answer?

Back pain and free weights?

I practice spine surgery in Monterey, California, which is home to the Naval Post Graduate School and the Defense Language Institute.  In the years that I’ve been in practice I’ve seen a lot of active duty soldiers rotate through Monterey for advanced degrees or language proficiency training.  They share similar histories.  They are fit, strong, and all of them have a lot of “mileage” on their backs.  Running around the desert with a heavy rucksack on, or jumping in and out of helicopters in the middle of the night is certain to cause back pain at some point.  Most of these soldiers report that they were fine while they were with their units in Afghanistan or Iraq and their back pain was manageable.  If anything, it was made better by staying active.  However, once they are crammed into a desk learning 40+ words of a foreign language a day, their backs start to ache.

Back pain and military service

Not surprisingly, all of their MRI scans are abnormal with degenerative changes typical of someone who is used to carrying a heavy rucksack and jumping in and out of a helicopter for a living.  I’ve help enough of them rehabilitate themselves that I know they are able to return to active duty, including paratrooper and flight duty, in spite of relatively significant degenerative changes and disk bulges.  I have also performed enough microscopic decompression surgery on active duty soldiers to know that after a well done microdiscectomy they will pass their fit for duty physicals and can return to service.  However, if they have a fusion, their military careers are basically over.

Since this is a patient population that prides itself on strength, endurance, and toughness, I get asked a lot of questions about strength training for both non-operative and post-operative rehabilitation.  My response is always encouraging, with a caveat.  Just like your mother said, POSTURE is IMPORTANT.  In my opinion, the following article does a great job of summarizing the arguments in favor of strength training as a way of avoiding back pain — especially the counter-intuitive exercises like deadlifting and squatting.

https://pjmedia.com/lifestyle/2016/11/30/back-pain-and-back-strength/

back-pain-and-strength-training

I caution these patients that this is one of those times where form truly is more important than function.  It’s better to lift correctly than to lift heavily, especially if your back is already injured.  I also believe that Kelly Starrett — of mobilityWOD and Becoming a Supple Leopard fame — is probably the most articulate advocate for proper form.

Is weight lifting safe if you have back pain?

The clear answer is Yes.  As long as it is done correctly.  If you are getting back into the gym after an episode of low back pain, or if you are rehabilitating after surgery, get some help.  Find someone who is really knowledgeable, like a strength and conditioning coach or a really good physical therapist.  Make sure your form is perfect.  Start light, and work your way up.  Done properly, even deadlifts and squats can help reduce back pain.

anterior microforaminotomy opening

Cervical microforaminotomy versus anterior cervical discectomy and fusion

Why we do Microforaminotomy surgery instead of fusions for neck and arm pain

My neurosurgical partner, Dr. Dimitrov, and I got interested in cervical microforaminotomies in 2010.  Our very first patient was a local big wave surfer who had arthritis and disk herniations at three levels in the cervical spine.  With 3 level cervical disk disease, and occasional episodes of severe neck pain, he had been told over and over again that #1 he needed a 3 level fusion, and #2 after the fusion, he wasn’t going to be able to surf big waves again.  I know him socially, and he asked me for a second opinion.

When I had the chance to examine him, it was clear that he only had pain in his left C6 nerve root distribution.  When I gave him a pain diagram to complete, he circled this image.

His MRI scan showed that he while he did have 3 level degenerative disk disease in his cervical spine, he had a large extruded disk fragment and a bone spur compressing the nerve root on the left side.  We discussed his options and because he was adamant that he would rather live with the pain and the muscle weakness than have a fusion and have to give up surfing, we discussed performing an anterior cervical foraminotomy.  I gave him a number of articles from the literature to read and he agreed that this seemed like a very reasonable approach.  We did his operation, his pain disappeared, and his strength came back.  Understandly, he was delighted.  Even better, he was convinced that he’d avoided a big operation that would have left him partially disabled.  I agreed.  He sent his friends, and they sent their friends, and now this is an operation that we perform frequently.  Happy surfers make for happy surgeons.

Here’s an explanation of the anterior cervical microforaminotomy as an alternative to a cervical fusion.

Medical definitions that you need to know

First, a couple of simple definitions.  The medical term for neck and arm pain caused by a herniated disk is “cervical radiculopathy”.

The word radiculopathy is composed to two words with latin origins.  The word “radix” means root and the word “opathy” means a disease of.  A herniated disk puts pressure on the root of the nerve and causes pain every where the nerve travels.

A herniated disk usually squeezes the nerve root as it tries to leave the spinal canal through a small bony tunnel called the neuroforamen.  The word neuroforamen also has latin origins.   “neuro” is the latin word for nerve and “foramen” is the latin word for an opening.

MRI findings that cause cervical radiculopathy

Ok, now that we understand those two terms, let’s look at an MRI scan of the cervical spine.  This view is called the saggital view and there are 7 vertebrae in the cervical spine, C1 through C7.  Between each of these bones are the intervertebral disks.  Here at the C5-6 level there is a disk herniation.  On this view we can see how the disk is bulging out towards the spinal cord and the nerve roots and when we switch to a cross-section, called the axial view, we can see how the disk bulge is off to one side and putting pressure on the nerve root as it travels through the neuroforamen.

The location of the pain is a clue as to which nerve root is being affected.  The cervical nerve roots travel to particular parts of the arm and the hand.  We have our patients complete a pain diagram and a pain journal and this helps us confirm which nerve root is irritated and inflamed by the herniated disk.

Non-operative treament and fusion surgery

When the symptoms of a cervical radiculopathy do not get better with non-operative treatment that includes physical therapy and anti-inflammatory medications, most patients realize that they may need a surgical solution for their pain.  They need the pressure to be taken off the nerve root so that the pain will stop.

The standard operation for a herniated cervical disk is something called an anterior cervical discectomy and fusion.  This is a surgical procedure that removes the damaged intervertebral disk and replaces it with a spacer and titanium plate, stabilizing that level.  This operation reliably alleviates the pain from a herniated disk, but unfortunately, fusing one level in the cervical spine increases the mechanical stress on the adjacent levels in the cervical spine and accelerates the natural degenerative process that occurs with age.  This can lead to a loss of range of motion, more pain, and more surgery in the future.

The results of cervical fusion surgery can be very good, but many younger patients who are athletically active would really like to avoid a fusion.

Cervical microforaminotomy — an alternative to fusion surgery
There is an excellent operation for this problem that completely avoids a fusion.  This operation is called an anterior cervical microforaminotomy.  It has an excellent track record in the medical literature.

In fact, the former head of neurosurgery at the University of California in Los Angeles remarked in one of his papers that “Patients treated with the anterior cervical neural foraminotomy procedure have equivalent or better outcomes than those who undergo current cervical procedures. It appears to be a good procedure for carefully selected patients with one sided cervical radiculopathy and avoids a fusion of the disc space.”

In this operation, a small incision about 1 inch long is made in the front of the neck and the damaged disk is exposed with the help of a microscope.  A tiny tunnel is created in the disk and the surgeon works all the way back to the nerve root, lifting the herniated fragments of disk off the nerve root.  Because the operation requires removing less than 20% of the disk, a fusion is not necessary.

In these still images from an operating microscope we can see the surgeon using a special neurosurgical tool called a kerrison rongeur to clean the herniated disk off the nerve root.  The surgeon is working through a small channel in the disk that measures 1/8 of an inch by 1/4 of an inch.

Here are the before and after MRI images of the spine demonstrating removal of the herniated disk with an increase in the size of the neuroforamen.

After this procedure the patient can return to normal activities within two weeks.  We advise patients to avoid sports such as mountain biking, horseback riding, and surfing for 6 weeks, but after everything has healed we expect all of our patients to have normal range of motion of the neck and no activity restrictions.

At the minimus institute in Monterey, California, we specialize in motion preserving procedures for cervical disk disease.  We want to see all of our patients free from pain and able to return to the activities that they love.

If you are interested in a cervical microforamiotomy or alternatives to fusion surgery, contact our concierge and we will arrange to have your MRI scan reviewed by one of our surgeons.

MRI review to see if you are a candidate for a microforaminotomy

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Terms of Service for MRI review

This website and the information presented here is for information purposes only.  The process of having your MRI scan reviewed is also for informational purposes only and is not a form of diagnosis.  A diagnosis and a final determination of whether you may benefit from medical treatment including spine surgery can only be made after you have been physically examined by Sohrab Gollogly MD, Dragan Dimitrov MD, or another one of the medical professionals affiliated with Monterey Spine and Joint, Monterey Peninsula Surgery Center or the Minimus Institute.

An initial review of your imaging data, including your MRI scan is for informational purposes only, has no value, and will not be billed. MRI reviews are preliminary, and some patients’ individual medical conditions may require additional testing.

The opinions expressed in patient testimonials are by patients only; they are not qualified medical professionals. These opinions should not be relied upon as, or in place of, the medical advice of a licensed doctor or other health care provider. Your personal health information can be shared with employees, providers, partners, affiliates, business associates or subsidiaries of Sohrab Gollogly MD, Monterey Spine and Joint, Monterey Peninsula Surgery Center, or the Minimus Institute.

By filling out any of the forms on this website, you acknowledge that (1) The MRI review is only an informational review of the documents and images that you are providing; and (2) The information provided by Sohrab Gollogly MD is not a diagnosis or definitive treatment plan.  This process if for information purposes only in order to give you a general understanding of the types of treatments available.  A diagnosis can only be made if you have been physically examined in Monterey, California by Sohrab Gollogly MD or Dragan Dimitrov MD.

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Sohrab Gollogly, MD is a board-certified orthopedic surgeon and Fellowship-trained spine surgeon who also performs scientific research and participates in several volunteer surgical organizations.

Dr. Gollogly completed his undergraduate education in biology at Reed College in Portland, Ore. He earned his medical degree from the University of Washington School of Medicine.

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