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Neurology (Expert Forum)
Cervical Surgery
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Cervical Surgery
by EdnaB, Jun 07, 2000 12:00AM
Over a year ago I began to suffer from dysphagia. I went to an ENT, he scoped me and only indicated that I had post nasal drip probably from my pollen allergies. He sent me for a barium swallow. That was normal, although the radiologist indicated that I would not bolus a significant amount of barium and the speech pathologist present said that my dysphagia was due to being nervous and that I needed to relax. Next I had a video swallow study. Again nothing of note. The ENT sent me to a GI MD, upon hearing my symptoms he suggested that I may have myasenthnia and sent me for an MRI of my brain. Radiologist reported everything normal. GI MD sent me to a Neurologist, he didn't feel that I had any other neural deficits and believed that I was having throat spasms. He started me on Lorazipam. The initial dosage put me to sleep. So he had me cut back and gradually increase dosage. I didn't have any improvement in the dysphagia but, I certainly was less anxious about it. One day I drove through a red light and that day I quit taking the lorazipam. I decided that the dysphagia was just something I was going to have to live with and maybe, just maybe it was all in my head.
This past winter I started windsurfing and one day I woke up with intense head/neck pain, alot of swelling in my neck and shoulders and was dizzy. I went to work but got sent home. From there I went to a walk in medical center they diagnosed me with an URI (I don't know how they came up with that diagnosis) and prescribed antibiotics. I returned there the following week because of no improvement in my condition. They told me to go see my GP. He sent me to a different neurologist. This neurologist took one look at the MRI of brain (done last fall) and said, oh my, look at your cerebellum! He immediately did an MRI of my neck.
Here's what we found: The sagittal images show a prominent crescent-shaped density posterior to the C4-5 disc space, having the appearance of a prominent herniation extending along the posterior C4 vertebral body nearly its entire length. On the saigttal images, this appears to be central and left paracentral. There is also a posterior disc protrusion C5-6, significantly less prominent than the findings at C4-5. The cerebellar tonsils end at just below the foramen magnum, but this is not a Arnold-Chiar I malformation. The axial images show a prominent broad left paracentral and left lateral C4-5 disc herniation with mild mass effect upon the cervical cord but no effacement. The bony neural foramina appear normal. This is likely an acute left-sided herniation. At C5-6, there is a mild central bulge without mass effect upon the thecal sac and also with normal neural froamina. Conclusion: There is a rather broad left paracentral and left lateral C4-5 disc herniation with significant migration along the posterior aspect of the C4 vertebral body. This is likely an acute herniation, and there is significan mass effect upon the thecal sac but no effacement of the cervical cord which is, however, slightly displaced posteriorly. The bony neural foramina are normal. There is a mild broad central disc bulge at C5-6.
I've been through 12 sessions of PT and tolerated all except the traction and massage/myofascial work on my anterior neck. I have a bit more ROM now, but the head/neck pain is unrelenting. I also have pain/numbness and clumsiness in both wrists, palms and little and ring fingers of both hands. Sitting for any period of time is difficult and causes increased discomfort in my upper back and neck. I can get relief by lying down. And by the way, I have not taken any pain meds, I just tolerate the pain and I could live with all those symptoms. The dysphagia is psychologically distressing but, I have learned to adapt; sips, small bites, no pills, no rushing through a meal.
I have always been active, surfing, skiing, rollerblading, raquetball - now I'm not supposed to do anything to increase the pressure on my spinal cord. This neurologist said that my cervical area is extremely unstable and to be verrrry, verrrrrry careful.
Last week I had EMG studies on my arms and don't yet have the results. He also suggests that I have the steroidal epidural injections. Which after some research I have decided not to do.
So anyhow, in your opinion, what options do you see for me to return a somewhat active lifestyle (and work, too). Pain relief isn't a big issue with me, I can deal with that. Do you think that surgery would be a likely option. Would the situation with my cerebellar tonsils be a challenge/complication to surgery.
Thanks for your interest.
EdnaB
This past winter I started windsurfing and one day I woke up with intense head/neck pain, alot of swelling in my neck and shoulders and was dizzy. I went to work but got sent home. From there I went to a walk in medical center they diagnosed me with an URI (I don't know how they came up with that diagnosis) and prescribed antibiotics. I returned there the following week because of no improvement in my condition. They told me to go see my GP. He sent me to a different neurologist. This neurologist took one look at the MRI of brain (done last fall) and said, oh my, look at your cerebellum! He immediately did an MRI of my neck.
Here's what we found: The sagittal images show a prominent crescent-shaped density posterior to the C4-5 disc space, having the appearance of a prominent herniation extending along the posterior C4 vertebral body nearly its entire length. On the saigttal images, this appears to be central and left paracentral. There is also a posterior disc protrusion C5-6, significantly less prominent than the findings at C4-5. The cerebellar tonsils end at just below the foramen magnum, but this is not a Arnold-Chiar I malformation. The axial images show a prominent broad left paracentral and left lateral C4-5 disc herniation with mild mass effect upon the cervical cord but no effacement. The bony neural foramina appear normal. This is likely an acute left-sided herniation. At C5-6, there is a mild central bulge without mass effect upon the thecal sac and also with normal neural froamina. Conclusion: There is a rather broad left paracentral and left lateral C4-5 disc herniation with significant migration along the posterior aspect of the C4 vertebral body. This is likely an acute herniation, and there is significan mass effect upon the thecal sac but no effacement of the cervical cord which is, however, slightly displaced posteriorly. The bony neural foramina are normal. There is a mild broad central disc bulge at C5-6.
I've been through 12 sessions of PT and tolerated all except the traction and massage/myofascial work on my anterior neck. I have a bit more ROM now, but the head/neck pain is unrelenting. I also have pain/numbness and clumsiness in both wrists, palms and little and ring fingers of both hands. Sitting for any period of time is difficult and causes increased discomfort in my upper back and neck. I can get relief by lying down. And by the way, I have not taken any pain meds, I just tolerate the pain and I could live with all those symptoms. The dysphagia is psychologically distressing but, I have learned to adapt; sips, small bites, no pills, no rushing through a meal.
I have always been active, surfing, skiing, rollerblading, raquetball - now I'm not supposed to do anything to increase the pressure on my spinal cord. This neurologist said that my cervical area is extremely unstable and to be verrrry, verrrrrry careful.
Last week I had EMG studies on my arms and don't yet have the results. He also suggests that I have the steroidal epidural injections. Which after some research I have decided not to do.
So anyhow, in your opinion, what options do you see for me to return a somewhat active lifestyle (and work, too). Pain relief isn't a big issue with me, I can deal with that. Do you think that surgery would be a likely option. Would the situation with my cerebellar tonsils be a challenge/complication to surgery.
Thanks for your interest.
EdnaB
Doctor's Answer
by CCF Neuro[P] MD, RPS, Jun 07, 2000 12:00AM
Dear EdnaB:
Sorry to hear about your neck. I think that most of us think that surgery is the last resort, after all else has failed. With only 12 PT and rehab visits, there is still much work that can be done in this area. This would be especially important, since although you have disc herniation, there is no compromise of the cord. There does not seem to be foramen changes (this is the space where the nerve roots exit). I would precede to do the PT and rehab work. I would be careful with activities, but use of proper form and some restraint might allow you to keep all your activities up and going. I would however, stay away from the pipeline in hawaii, large swells at Mavericks, strong south swell at Ralphs, etc.
CCF Neuro MD
Sorry to hear about your neck. I think that most of us think that surgery is the last resort, after all else has failed. With only 12 PT and rehab visits, there is still much work that can be done in this area. This would be especially important, since although you have disc herniation, there is no compromise of the cord. There does not seem to be foramen changes (this is the space where the nerve roots exit). I would precede to do the PT and rehab work. I would be careful with activities, but use of proper form and some restraint might allow you to keep all your activities up and going. I would however, stay away from the pipeline in hawaii, large swells at Mavericks, strong south swell at Ralphs, etc.
CCF Neuro MD
Thanks!
I'm not aware of severe disc herniations causing brain herniations. In my situation the cerebellar tonsils extend below the foramen magnum which is further than what would be considered normal. Why are my cerebellar tonsils like this? I don't know. My neurologist said that I was born this way. My concern is that this might be more difficult for a NS to do repair work.
Have a good day.
Edna B
Thanks for responding.
You said yours is not Arnold Chiari Malformation, nor is mine.
I noticed that your neuro did immediate MRI's of your neck so I assumed the herniation and disc were related.
Interestingly I developed an empty sella, sleep apnea and some cranial nerve dysfunctions. Bottom line for me is that I have a cerebellar herniation, and the herniation is neurodegenerative.
I have seen 2 neuro MD's. I had the MRI of my brain in Sept '99; both the radiologist who read the MRI and the first neuro MD said that the pictures were unremarkable. It was six months later when I went to a different neurologist that any notice was given to my cerebellum. Initially the 2nd neuro MD suspected a virus or CA and that's why he did the MRI of my neck to see how far the cerebellum extended and discovered the herniated discs. He told me not to worry about the cerebellar tonsils. From what I learn from you maybe there is a connection here between my cerebellum and herniated discs........ Maybe I should be concerned. What do you think?
I live in a small town and I think that I need to go to visit a more versatile neuro environment. As you can see, the CCF MD didn't seem too concerned about my situation. I know that there are many people with greater and more pressing problems than my own but that doesn't negate my situation. Like most people I'd like to get better and I realize that wasted time can work against positive outcomes.
Now tell me, what is empty sella?
EdnaB
I think that it is the change in the Cerebral Spinal Fluid dynamics that tends to cause problems. A cine MRI can be done to see if there is some kind of blockage.
There are several doctors that specialize in this kind of stuff. One is named Milharat at SUNY in New York. There are several on the West Coast, I have forgotten their names.
I thought dysphagia could be a brain