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Disc / Ligament Injury - Treatment Suggestions ?
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Disc / Ligament Injury - Treatment Suggestions ?

I was the driver of a vehicle that was stopped when I was hit by a DUI driver from behind at 65mph.  This occurred on 04/28/08.

Immediately following the collision, I had pain and stiffness in my neck, and tingling in my left facial cheek.  Severe pain in my neck, mid, and lower back set in within two hours.  Extreme paresthesia in all of my extremities, and lower face set in within eight hours.

A cervical and lumbar MRI was done two days following the collision. These are the results:

Cervical MRI:
     IMPRESSION:  No evidence for fracture or ligamentous injuries, Mild reversal of cervical lordosis, Mild degenerative disc at C4/5 with possible annular fissure.
     SPECIFIC:  At C4/5, mild anterior intervertebral disc space narrowing is present.  Diffuse disc-osteophyte complex flattens the thecal sac, but does not result in central stenosis.  Linear T2 hyperintensity is present within the posterior aspect of annulus. No neural foraminal narrowing is present.

Lumbar MRI:
     IMPRESSION:  Mild disc degeneration at L4/5 associated with a small posterior central annular fissure.
     SPECIFIC:  At L4/5, mild posterior intervertebral disc space narrowing and decreased disc signal are present.  Minimal circumferential annular bulge flattens the thecal sac and is associated with a small posterior annular fissure.  No central spinal stenosis, neural foraminal narrowing or neural impingement is present.

I had a Thoracic MRI done three weeks later.  This is the report:
     IMPRESSION:  Mild bulging disc in the lower cervical, C6/7, C7/T1,T3/4,T4/5 levels are seen.  No evidence of significant spinal stenosis or forminal narrowing is present.
     SPECIFIC:  Mild degenerative changes of the upper thoracic spine and lower cervical spine are seen.  Artifacts in the thoracic spine, at the thoracolumbar juction are present however.  The thoracic cord is normal in size and signal.  There are pulsation artifacts within the thecal sac.  Mild bulging disc at T3/4 level is noted.  Mild bulging disc at T4/5 also noted.  The cord terminates at T12 level.  There is posterior mild bulging disc at C6/7 and C7/T1 levels in the lower cervical spine noted as well.

My pain in my neck and lower back has persisted, at a constant level of 5-6, increasing to 7-9 on exertion, exercise, or prolonged position (static sitting, or standing).  My paresthesia in my extremities has decreased overall in intensity, but persists, is constant, and also increases with activity.  I have also developed intense radiculopathy burning in my arms and legs, radiating down to my fingers and toes, along the C8 dermatomes, and the L5/S1 dermatomes.

The doctors of my HMO have failed to diagnose or treat any of my issues, having labeled everything as "Degenerative Disc Disease".  

I have taken NSAIDs for over a year, resulting only in increased reflux issues.  I have taken Neurontin, Lyrica, Flexeril, Zanaflex, Norco, and have found nothing that provides relief.  I took the 6 day Medrol (Methylprednisone) course, which increased the radiculopathy and paresthesia.

I have tried chiropractic, physical therapy, accupuncture, traction, and TENS therapy.  My symptoms and pain persist.

I have seen several physicians within my HMO.  None have seemed to be able to diagnose my issue, either because they were not knowledgeable or because their focus was too narrow.  I had two neurologists tell me "There are somethings in medicine we can't explain" and "All you need is a positive attitude, because that does more than any doctor can do for you."  I have seen four neurosurgeons, who only would address one area (cervical, lumbar).  The surgeons all said they saw issues, such as arachnoiditis and ligament damage, but nothing they would recommend treatment with surgery.  They told me it was not their job to diagnose any issues, and referred me back to the neurologists.

I had a DMX video fluoroscopy of my cervical spine done by an outside doctor.  This was the report:
     IMPRESSION:      Lateral translation greater than 3.5 mm during both left and right lateral bending indicates laxity of the right and left alar ligaments respectively and suggests possible instability. Correlate clinically.
    Anterior translation of C2 and C3 during flexion indicates posterior ligamentous laxity at those levels.
    Posterior translation of C2, C3, C4 and C5 during extension indicates anterior ligamentous laxity at those levels.
    Degenerative disc disease C4/C5-C6/C7.
    Hypolordosis, possibly due to myospasm.  

     SPECIFIC:  Standard fluoroscopic views of the cervical spine are submitted for interpretation. There is straightening of the cervical lordosis. The intervertebral disc spaces C4/C5-C6/C7 are diminished in height. Overall bone density is adequate.

     FLEXION AND EXTENSION MOTION OF THE CERVICAL SPINE: During flexion, there is a 2.0 mm anterior translation of C2 with a 1.0 mm translation of C3.  During extension there is a 2.0 mm posterior translation of C3 and C4 with a 1.0 mm translation of C2 and C5.

     FLEXION AND EXTENSION MOTION IN THE OBLIQUE POSITION:   During flexion and extension there is contiguous motion of the facets with patency of the intervertebral foramina from that noted during neutral posture.

     LATERAL BENDING MOTION OF THE CERVICAL SPINE:   Left and right lateral bending demonstrates normal intersegmental motion.

     LATERAL BENDING MOTION OF THE UPPER CERVICAL SPINE:   During right lateral bending there is a 3.0 mm lateral translation of C1 upon C2. There is a 4.0 mm lateral translation noted during left lateral bending. There is associated narrowing of the para-odontoid space during both left and right lateral bending.

     ROTATION MOTION OF THE CERVICAL SPINE:   Left and right rotation demonstrate normal intersegmental motion.

I am coming to my wit's end.  I am in constant pain, with constant burning and tingling in my extremities.  I have seen several doctors, and none have so far put the whole package together and told me what is wrong, or offered a solution or prognosis.  I have tried all drug therapies, with no success.  No one seems to be able to treat the cause.

The outside doctor recommended prolotherapy to treat the ligament damage, and I am looking into that, but it is not covered by my HMO.

Can you provide any recommendation or possible treatment routes to follow?  I am an active person, a law enforcement officer, and am desperate to return to my former life.
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Sorry to hear of your prolonged pain and difficulty in finding significant relief.  The testing and imaging studies done during the course of your treatment do indicate the presence of degenerative disc disease without any significant nerve involvement or stenosis (narrowing) of the central canal through which the spinal cord travels.

The abnormalities in curvature (straightening of lordosis) can be related to muscle spasms and can contribute to the overall disabling situation.  

The extension/flexion studies do support the evidence of ligament laxity which can also contribute to destabilization of the spine. The pain results from the extra movement of the spine and the bones rubbing together.  The friction can also lead to the development of bone spurs and other bone hypertrophy.  The recovery from ligament injuries is more difficult secondary to the decreased blood supply and incomplete healing.

Prolotherapy is considered an alternative approach to healing and strengthening the ligaments/tendons as opposed to more conventional approaches such as physical therapy. steroid treatments and/or surgery and finding a specialist proficient in this approach may be difficult.  The treatment not being a covered benefit with your HMO magnifies the problem.

Have you discussed this treatment with any of the consultants you have seen?  Did the outside doctor provide you with a detailed report including the recommendations for prolotherapy?   Have you done sufficient research to validate outcomes of this approach?

It may be beneficial to have a one-time consult with a prolotherapy consultant to obtain specifics about the treatment and the anticipated cost.  HMO decisions regarding approved therapies are usually rather stringent, but an appeals process may be possible with sufficient medical documentation.  Most newer and less utilized procedures/treatments tend to be considered "experimental", but prior experimental therapies have now been more accepted.  Artificial disc replacement has been done for many years in Europe and is still relatively new in the USA since spinal fusion is considered the gold standard for many disc problems,  

This is an arduous process for you as evidenced by the number of specialists you have consulted.  Four neurosurgeons seem to agree that surgical intervention is not indicated.
If you are unable to get approval from your HMO and are unable to afford the out-of-pocket expenses, a referral to a pain management specialist may help (as a final effort in coping with the constant pain).

Hoping you have some resolution soon.  Keep us posted of your progress.



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Avatar_f_tn
I was injured much like yourself.  After two years of suffering, I decided to give prolotherapy a try and have found it to be remarkable improvement with it.  I have an injury to the C0-C1 joint, as well as several buldging discs further down.  I have had my chest, cervical spine, thoracic spine, ribs, levelor scapular and a few other places treated.  You will need to have patience with the treatments because it does take time to see results.  It is the only thing that has kept me from jumping the bridge.  If you live on the east cost, check out Dr. Mayo Friedlis,  If you are in the midwest, find Dr. Mark Canteri, and there is another guy on the west coast in Washington and Dr. Canteri can put you in touch with him or someone in your area.  That is how I found Dr. Friedlis.  Be sure to find an experience prolotherapist if your case is complicated.

Got any questions, just find me and I will be happy to chat.

Hope
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