Disc reshaping the cord

Posted by Lynn on June 29, 1999 at 09:28:56
I have a severely herniated disc at T7-8 (one among seven in the thoracic area).  This was diagnosed over 3 years ago via myelogram/CT after conflicting opinions over the MRI's done.  I had a repeat MRI over a month ago of the brain and entire spine w/wo contrast.  This scan seems to show that the disc at T7-8 is reshaping the cord.  The myelogram/CT showed the cord in a kidney shape centrally.  The NS felt that the disc was stucked to the cord and that the cord was draping over the disc.  The other thing that was very apparent on the brain MRI are numerous white spots.  I had a spinal tap almost a month ago that came back negative.  I have never had s/s that were suggestive of MS.  MY questions are 1.  Since they are talking decompression what is going to happen to the cord ?  I have read in a medical article that if the the cord is draped over the disc that the dura needs to be lifted and this should be avoided.  Is thePosted by Anni e K on June 30, 1999 at 18:19:36
Sorry I did not give you enough information...I had/have Cauda Equina at the L4-L5 and had surgery for the herniation in 98....microdiscectomy, laminectomy and spinal decompression...it is now a year later and my right leg is not only numb from the L5 pattern exhibited before surgery...I am having constant low back pain as well...but the newest symptom is my right knee hurting and it does not "flex and lock" as my normal (left) leg does...I do believe the "foramen" you mention was removed at surgery...my PT explained this to me...here is the full report and I thank you for taking time to read and explain....History: Post op. Recurrent low back and right leg symptoms.
Findings:  The lumbar spine was image in the sagittal and axial planes pre and post contrst utilizing T1 and T2 weighted sequences.  Comparisonn is made to the prior exam of 5/11/98...the conus is normal. Bone marrow is intact and the alignment of the spine is anatomic. Disc spaces are normal dpwn thru L3-L4.  At L4-L5 there are post operative changes observed .   There is enhancing epidural fibrosis seen in the vental and right lateral aspect of the spinal canal.  This extends to and involves the orgin of the right L5 nerve root.  There is no evidence of disc recurrence.  Defect with the posterior disc annulus is seen and there is enhancing epidural fibrosis/granulation tissue which extends into the central aspect of the L4-L5 disc space.  There is no MR evidence of frank disitis.  The L5-S1 is unremarkable.  IMPRESSION: POST OPERATIVE CHANGES OF ENHANCING EPIDURAL GRANULATION TISSUE/FIBROSIS.  THIS ESPECIALLY INVOLVES THE ORIGIN OF THE RIGHT L5 NERVE ROOT.  CORRELATE FOR A RIGHT L5 RADICULOPATHY.  NO EVIDENCE OF RESIDUAL OR RECURRENT DISC HERNIATION IS SEEN.  THE OTHER DIS SPACES ARE UNREMARKABLE.  NO OTHER ABNORMALITIES ARE OBSERVED.  End of report...I am not certain exactly what this means...the thecal sac was compressed 6 months before surgery...and my back pain has never stopped and has increased measurably over the last 3- months as well as my right leg/knee...I have minimal reflex in the right knee (at one point after surgery it was a 2) now it is almost absent as is my ankle reflex on the right leg..the left leg is also weak in the knee and ankle reflex..which it had always been normal previously....is the scar tissue causing all this...and if so...will it get worse...and what does the radiologist mean when he states: There are some reactive changes in the marrow of the L4 and L5 vertebral bodies adjacent to the L4-5 disc space?  Thank you so very much for explaining this to me...could you help me if I came to the clinic...thanks.. Annie

Posted by Marcia on June 30, 1999 at 23:53:37
I am a 51 year old femalem and I too have reshaping of the cord...but mine is cervical.  The area in question is C-3 thru C-7. A recent MRI revealed stenosis at C-3/4, ( there is also a white line across the cord area on the mri at the C3/4 region),and the cord is pancake shaped at C-5/6 and 6/7.  I have reflex changes in my left leg..knee jerk is hyper reactive., dimished and absent reflexes in my elbows, weakness and fine motor coordination ( intermittantly) in both arms.  My NS proposes a fusion of C-3 thru C-7. ( What fun!!!), with titanium wires, removing the vertebral body at C-5.  My questions are:  How limited will my neck movement be after such a procedure?  I understand that the stability and risk of cord damage will be lessened with this surgery.  But WHAT limitations will I have after?  Will I be able to look at my feet?  How about sitting and writing at a desk?  Reading a book?  Peeling potatos?? I have osteoarthritis in multiple sites in my body...and may be facing a total knee replacement also.  I had the great toe joints "redesigned" last year bilaterally, and have a bulgeing disc at T-8.  I a first grade teacher, and am also concerned how this surgery will affect my ability to be responsive to the needs of my children in class. As a first grade teacher, I have to be ever observant of the actions of each of the children and ready to intervene in times of outbursts of poor behavior.  Not to mention the stooping, kneeling and floor activites that are a daily part of my job.  Will I be able to continue to do these kinds of activities? What are the risks of NOT having the surgery, and how likely are they to occur.  I wear an aspen neck brace most of the time to help the neck muscles support my head and take some of the load off of the bones.
Sorry this is so long...and thank you for your response.  

Posted by CCF Neuro[P] MD, RPS on July 01, 1999 at 17:22:14
Dear Marcia:
Sorry to hear about your cervical spine.  Actually, it sounds like you need surgery as you are having cord effects from the spinal compression.  This is usually one of the major criteria for surgery.  One does not what to have permament nerve damage from the compression.  Surgery is always patient and surgeon dependent.  I would also get a second opinion before you make your choice.  If you have to have surgery, your mindset needs to know that you absolutely need the surgery.  As far as what you ask about mobility, etc. that all depends on how severe the surgery and the surgeon.  Obviously you will be somewhat limited by from my experience you should see fairly good movement, much better that with a neck brace.
Sorry, I can't be more specific about how good you will be after surgery. I haven't had the opportunity to examine you.  Most, but not all the time, this sort of surgery brings benefit.  It is a long road of rehab.
Sincerely,
CCF Neuro MD

Posted by Laura B on July 26, 1999 at 22:37:05
What would your recommended course of action be for this problem?
I am 40 years old, and currently do not want to live to be 41.  Three years ago, after an MRI I was told everything was fine, but that I would live in pain always.  I am having severe pain that I can no longer tolerate, and the Dr. ordered an MRI.  I will undoubtedly seek a second opinion, and want to work with compassionate doctors that don't dismiss their patients with words of "there is nothing wrong and nothing I can do for you".   I do not want to become an unproductive member of society.  Additionally, I am having left leg pain, which I did NOT mention to the doctor because of the attitude I have been feeling from him.  I live in Illinois, and could get to your office for a second opinion.

Here is the interpretation from the MRI from 1 week ago.
Clinical Data: Prior disectomy with C6-7 fusion.  Neck pain with radiation to left arm.  Evaluate for disk herniation/nerve encroachment.
Again noted are the changes of diskectomy and anterior fusion performed at C5-6 and C6-7 with obliteration of intervertebral disk space signal at these levels.  There is reversal of cervical lordosis centered at C6.  Because of the slight kyphotic curvature, there is encroachment upon the ventral thecal sac, but the posterior subarachnoid space is patent and there is no frank cord compression.  There is some subtle increased signal within the cord at C5 - C7 levels, some of which may be artifact, but a component of myelomalacia is possible.  As mentioned previously, there has been anterior cervical fusion at C5-6 and C6-7.  There is susceptibility artifact emanating from the C6-7 disk which may represent some metallic fragments related to surgical drilling.  The C6 and C7 foramina are widely patent.  There may be a very minimal osteophytic spur at the C6-7 level, along the right paramedian margin.  A small amount of material is situated ventrally and mesially which encroaches minimally upon the ventral thecal sac.  There is mild flattening of the ventral surface of the cord at the C5-6 and C6-7 levels, but as mentioned previously, no frank cord compression.  Focal area of increased T1 signal within the C6 vertebral bodies consistent with hemangioma.  There is susceptibility artifact emanating from the ventral aspect of C7 - T1 junction, on the right, consistent with metallic artifact.
There is focal enhancement within the posterior mesial annulus at the C4-5 level.  There is small central disk prolapse at this level and the findings are consistent with radial tear with ingrowth of granulation tissue.  These findings were present on the prior study.  The neural foramina are widely patent bilaterally at this level.
There is abnormality involving the left C3-4 facet joint which appears widened with increased fluid.  The soft tissues around the facet joint appear thickened and enhance.  However, there is no edema within the paraspinous musculature and I think it is unlikely that these findings are infectious in etiology.  However, there is some encroachment upon the left C4 foramen.  These findings are not well visualized on the prior study.
Impression:
1. Post surgical changes C5-6 and C6-7 with anterior cervical fusion.  There is accentuated kyphosis at this level with flattening of the ventral surface of the cord, but no frank cord compression.  Subtle signal changes within the cord are of uncertain significance, but a component of myelomalacia is possible.
2. Small central disc prolapse C4-5 with enhancement of the posterior mesial annulus consistent with a radial tear and ingrowth of granulation tissue.  Not changed from prior exam 3/96. (The doctor failed to tell me this).
3. Left C3-4 facet arthropathy and possibly a component of synovitis. While this may be degenerative in etiology, other etiologies such as gout or Crystalline Deposition Diseases (CPPD) could give a similar appearance.  Infectious etiology is felt unlikely, but not excluded.  There is a component of soft tissue encroachment upon the left C4 foramen.  Further information may be gained by correlation with CT through this area.  
Thank you for your time.
Laura
Posted by CCF Neuro[P] MD, RPS on July 28, 1999 at 12:34:46
Dear Laura:
Sorry about your cervical spine problems.  It is difficult for someone to give a prognostication to a MRI on a patient whom he has never seen, let alone exam.  Most of what you have told about in the MRI report seems appropriate for the type of surgery you indicate happened.  For the most part, surgery is the last thing to do to relieve pressure or compromise of the spinal cord which is usually producing changes in the extremities.  I sure you were told that with surgery there are no promises and the outcome is patient-to-patient.  I am not sure what type of rehab you have had but this is extremely important.
It sounds like you are not happy with the care you have been given.  In light of this it is probably wise to get another opinion about your options.  Although there are changes on your MRI, there doesn't seem anything that is acutely dangerous or the etiology of all your pain.  Seek a second opinion from a neurosurgeon and maybe a neurologist.  See if he/she thinks that surgery remains an option to help relieve some of the pain.  Seek out the options of rehab, pain management, PT to help manage the result of the previous surgery.  The neurosurgeon should have people whom he or she has worked with in these various areas.  
If it looks like further surgery might help you, then coming to the Cleveland Clinic would be an appropriate thing to do, but rehab and the other things that need to be addressed (regardless of whether the surgery occurs) should be near where you live as this is a long process.  Get the second opinion first, then decide if further surgery is an option and then make a choice about it.
Sincerely,
CCF Neuro MD