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Dr Abhijeet PLEASe help
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Dr Abhijeet PLEASe help

I had ACDF surgery in 08/07.  I started experiencing burning pain on the right side of my neck approximately 6 weeks after surgery.. I have had several MRI's and the cervical ones indicated I have enlarged lymph nodes on the right side approximately 15millimeters in diameter. They were there presurgery as well. The surgeon says my bones are fused and evertything looks fine. My problem is this burning pain comes and goes on the right side of my neck and it has spread to under my breasts sometimes in the arms and now I have noticed my hands are turning red and they burn and sting as well.  It seems they turn red when the neck burns intensely. My sed rate on 2 different occasions was 27 and 35. My c reactive protein was normal. SOmething just doesnt feel right on the right side of my neck, it feels like a stretching pulling pain. I have seen 2 different neurologists and they have no answser for me. I havent had an EMG yet but think I should schedule one soon.  I am so worried about it and I want some answers. Are there any tests I can have done to get to the bottom of this."?  Could the titanium plate be causing this? I just need some answers and advice. I have an appt to see a Rheumatologist in late April. Please give me some guidance.
Thank you



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368886_tn?1278962315
Hello.

I am sorry I failed to notice your post earlier.

Since it's more than 6 weeks after the surgery, your burning pain has some nerve compression component to it.

I would like to ask if this burning and the pain you described were there prior to ACDF. If yes, was it more severe ?

The titanium plate does not seem to be involved here. It is just used to support the vertebral bodies.

I suspect some more disc protrusions after the surgery. Which discs were removed during the discectomy ? Since some vertebrae are fused together, the others have to bear extra pressure.

You can get an EMG/NCS done, but I would like to get an MRI of the cervical and upper thoracic spine again to see any more bulging or herniated discs.

Hope it was of some help.

Regards
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No I didnt have any of this burning pain prior to surgery. My symptoms prior to the surgery were left arm pain and left shoulder,scapula pain and left arm weakness.  The discs removed were C5-C6 and C6-C7. I started experiencing this intense burning pain approximately 6 weeks after the surgery. The pain also went into the back of my skull and down my right arm. For a while the pain was everyday nonstop for 3 months and then it began to taper where it was coming and going. The pain also was by my right ear. THen the burning began to spread to other parts of my body, for instance down my back and under my breasts and on my sides and so forth. I would like to give you my last MRI report if thats okay.  I have had a total of 6 MRI's since the surgery and no new herniations have shown up. My surgeon first said it could be the nerve root causing this pain but they still dont know as of yet. I have been undiagnosed still. I plan to have an EMG on Monday.  My question is what about the enlarged lymph nodes. The side of my neck that burns is on the right lateral side and also posterior as well.  I just want some answers thats all.  Here is the last MRI of my neck. I would like your advice.

MRI of the soft tissues of the neck without and with contrast:

Clinical information:right-sided neck pain and burning parethesias behind right ear. History of previous spinal fusion.
Technique: 1. Sagittal, axial, and coronal T1-weighted 5-mm images.
                  2. Axial and coronal T-2 weighted 4-mm images.
                 3.  Axial and coronal T-1 weighted 5-mm images after contrast admininstration with fat-saturation.
Comparison: There are no previous MR scans of the soft tissues of the neck available for comparison but there are outside MR scans of the soft tissues of the neck on 7/27/07 and 10/04/07. THis study was performed after the patient was premedicated for her gadolinium allergy with prednisone, zantac, and benadryl. There are postoperative changes of anterior cervical fusions as well as anterior plate and screw fixation from C-5 to C7. This causes some mild artifact. There are prominent level II nodes larger on the right side. THese show homogenous contrast enhancement and are no greater than 15mm in diameter, along their anterior superior axis. THese were also present on the outside MR scans of the cervical spine and have not significantly changed. I suspect that they represent benign reactive nodes. NO mass lesion is appreciated within the soft tissue of the neck.  THere is no evidence of a mass lesion in either lung apex.
Impression: 1. There are postoperative changes of anterior cervical fusion with instrumentation from C5 to C7. THis causes some minor artifact.
2.  THere are bilateral level II probable reactive nodes larger on the right side which in retrospect are unchanged from outside MR scans of the cervical spine on 7/07 and 10/07.
3. MR scan of the soft tissus of the neck is otherwise unremarkable.

So sorry it is so long. I also had an MRI of the thoracic spine but is was without contrast. It had no herniations. Please advise.
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Oh, I forgot to mention one more thing that could be of importance. I have a very minor posterior annular bulge, C7-T1 that does not impenge on the spinal cord.This was taken in 10/07.
The one taken prior to surgery said this--C7-T1. The disc is mildly narrowed. There is a posterior central disc protrusion that effaces the thecal sac but does not produce cord impingement. The neural foramina are of adequate caliber. Thanks for your help.
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Hello. Dr. Please advise. Thank you
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I am just trying to get bumped up so the doctor would respond. Please help. I am so worried.
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Dr Abhijeet..Would you please advise..I would kindly appreciate it..Thank you
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368886_tn?1278962315
Hello.

Your MRI does not confirm any nerve root impingement. But I strongly suspect there is ongoing injury to the nerve roots. The distribution of the burning is suggestive of this.

The next best to find out is the Nerve conduction study and EMG. I guess you are getting the EMG done today. Let me know what happens.

Regards
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Well thank you for your advice doctor. I had to postpone my EMG for next week. I am sick with the flu.. If I have nerve root injury, will it heal on its own? I hope I dont have to suffer with this the rest of my life.  Injury to the nerve roots can happen in surgery right? I will let you know how the EMG goes next week. I appreciate all your advice. THanks again.
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368886_tn?1278962315
Hi.

A nerve root injury should heal, but it may take a long time, especially if the source of injury is constant. Even without a compression, a nerve root can get irritated.

Regards
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Dr Abhijeet,

I am so worried. My hands have been turning red off and on. Do you believe the neck can be related to this? I am supposed to have my EMG on Friday. Oh, I noticed they were a lilttle purplish the other day. I am so concerned. I just hope I dont have nerve damage. What do you think of the enlarged lymph nodes that were noted on the MRI? SHould I be concerned of that too? I am lost. NO doctor has given me  a diagnosis as of yet. DO you think it would be wise to go see a neurosurgeon? Also should I get another CT scan to make sure my bones are fused? SOrry for all the questions. I just want some answers thats all.. THank you

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368886_tn?1278962315
Hello.

The lymph nodes could actually suggest some ongoing infection. And this might be the cause of the discoloration of the hands. Can you blanch the redness ? Make a firm fist, grip the wrist with the other hand, open the fist and see if the redness is still there or it has turned pale. If it does become pale, we can consider some blood circulation problem.

Have you talked to the doctors about the lymph node biopsy ? It will be a good idea to get it done to rule out infection.

You will have to check whether the implant used for the fusion is radioluscent for us to confirm it by CT scan.  You can actually get x-rays or CT scan to get the fusion confirmed. I think there is no problem with the fusion.

You could get the EMG done and then decide further plan of action. I am sorry for not being able to give you a diagnosis, but we can at least eliminate causes one by one.

Regards
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I have questioned doctors in regards to infection. My surgeon doesnt think it is, however he wasnt the one who ordered the sed rate and creactive protein.  One of the neurologists ordered these. She is going to do the EMG on Friday.  My question to you is my sed rate was 27 and 35 on 2 different occasions. Should I be concerned of this since they are mildly elevated for my age of 38? I believe the neurologist did mention something about a biopsy but one was never scheduled. Do I need to see an ENT doctor for the biopsy? What type of biopsy do I need?  So you dont believe the fusion is causing all the problems.?  I appreciate all your helpful advice. THank you. SOrry for all the questions. If you can give me any pointers to discuss with my neurologist on Friday let me know..
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368886_tn?1278962315
Hello.

As I mentioned earlier, even if the MRI shows no impingement, I still feel this could be due to a nerve compression. The lymph nodes have to be examined. The biopsy should be a Fine Needle Aspiration Biopsy. Infection is not the only cause. One more factor that can go against an acute infection is the normal C -reactive protein. Did you have any long term infections earlier  ? And can you relate the nodes to the onset of any symptoms, such as fever, pain or any other complaint ?

I guess you can stress the FNAC part to the neurologist. A histo-pathologist will do the biopsy. If it is a CT - guided FNAC, you will be going to a radiologist.

It is probable that the fusion has resulted in other discs to bulge more than they normally would have done. The EMG would be a great help.

Regards
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I did not have any long term infections earlier.  I had pain when the injury happened in my left scapula and left arm excruciating pain before the surgery. I had 2 ruptured disks and surgery was my only option.  I do not recall running a fever or anything like that. I appreciate all your good advise. IT has been very helpful to me. Are you a neurologist? I will let you know how the EMG goes. It will be done on Friday. How long does it take for the results? THanks again.

Bye
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Oh I forgot to mention I did have C REactive PRotein drawn and it was normal the result was 0.10 drawn in 12/07. My ANA was negative as well.  I also had Creatine Kinase, total serum drawn which was normal at 63.  My TSH was 2.826. THese were drawn in December. So I am not sure the cause of this. Thanks again
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368886_tn?1278962315
Hello.

The lymph nodes may be enlarged as a result of some small injury or a reaction.

I am sorry if we could not come to any final conclusion, after a long discussion. Please let me know about the EMG.

Regards
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Hello,

Well. I just finished the EMG. My neurologist says its normal.  I guess that is good. However I still think there is something significant going on in my neck that is causing these symptoms I am having. I am still concerned. And yes it was a little painful. I am still sore from it especially my right arm.  She said maybe I should wait on the biopsy and she wouldnt be the one to order it anyways. She says my primary care doctor needs to. SHe thinks I should have a repeat MRI in 6 months to compare it to the previous one. Since the other MRI's showed that the lymph nodes have been consistently the same size and havent changed. What is your impression?  I am still worried and I know I am not making up what I am feeling. Please advise.
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Hi.

In view of the current situation, I would go for the biopsy as soon as possible. The lymph nodes can be of infective origin. It may be a virus, or it may be bacterial, as a result of an infection from the surgery. The organism has to enter the body from somewhere.

Regards
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Just one more question. You saw the MRI report. It says those were there on the MRI prior to my surgery. My surgeon also says these were enlarged prior to the surgery but didnt mention it to me then. Now do you still believe it could be an infection of some sort? And you believe I should proceed with the biopsy.? THanks again
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Also,

Isn't it true that diagnosing a cervical infection is quite difficult? I heard that sometimes they are missed and caught later on. If it is an infection, isnt that a serious thing? Wouldnt I have to go back in to the hospital for a heavy course of IV antibiotics. THis shouldnt be taken lightly correct? THanks again
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368886_tn?1278962315
Hi.

I would reframe my earlier sentence by saying that the surgery may have increased the already enlarged lymph nodes, if they are from an ongoing infection.

Cervical infections are common. In fact, cervical nodes may get enlarged by non-cervical infections too. For example, an infection somewhere in the hand can travel up and the lymph nodes in the axilla get enlarged. Neck lymph nodes are the second last stage before the lymph gets mixed with blood again. The infections could have been from any region around the neck .

but most of the cervical infections are diagnosed with clinical history and a prompt biopsy. I am surprised the doctors are reluctant to get a biopsy done.

How is your burning pain now ? And I would again stress the need of a biopsy. There is no acute infection, as you C reactive protein is normal.

Regards
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THanks so much for all your helpful advice. I believe the doctors here that I have seen are clueless. I dont mean that in a bad way. ITs just that they havent been very proactive with running tests. As a nurse I am very frustrated in how I have been handled. I know there is something wrong and I want to know what it is. Yes I still have the burning pain but it comes and goes. TOday I had some minor burning pain in the right side of my neck and it is quite sore from the EMG. I was the one who called my doctor to get this test done. THe neurologist and my primary care doctor werent too concerned about the enlarged lymph nodes. I saw the neurologist today and I saw my primary back in January as well as the surgeon. My burning pain has spread to other parts of my body like under my breasts sometimes, in my abd and so forth. However it is intermittent. NOw I too was concerned about some sort of infection when all this began and questioned my doctors on a number of occasions and they shook their head. All these symptoms began 6 weeks after the surgery and continued for 3 months constant burning pain and it started to subside in Jan. I just want some answers and if you think a biopsy is of importance I couldnt agree with you more. I guess I need to make an appt with my primary care doctor to get the ball rolling. Thanks again
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Dr. Abhijeet,

Hello again. Wouldn't a cervical infection show up on MRI?? The last cervical MRI I had was in December and it was with contrast and it showed no infection? YOu saw the report.  I have had 3 MRI's since surgery. Or is it possible that it wouldn't show up because it isn't acute anymore?? I am just trying to figure things out.  I have appt to see my primary care doctor on Monday to discuss issues about biopsy.  My neurologist said that having a biopsy of the cervical lymph has its risks such as damaging the brachial plexus the area she said I was having problems with. What is your opinion? Do you think I should get a 2nd opinion from a neurosurgeon since the neurologist is baffled?  I just need your honest advice. You have been very helpful. thank you
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368886_tn?1278962315
Hello.

MRI may not show infection. And if the lymph nodes are due to infection, it is not an acute infection. I was also thinking of a post surgery thrombophlebitis, but it should not continue for such a long time.

The biopsy procedure may have its risks, but most of the documented risks are from the years when there was no CT guided FNAC. Now, with the imaging technique at hand, the biopsy can be as safe as any other investigative procedure.

I am a little surprised to read that the nerve conduction study done recently is normal. I was suspecting nerve compression. But now it is difficult to tell why you still have the burning pain.

It is necessary to know the cause of the lymph node enlargement. We can't just leave them unexplained.

I would be waiting for what your physician says about biopsy.

Regards
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Hello again,

I forgot to mention to u that I did bring up a biopsy to my internal medicine doctor back in January. HE wasn't concerned. He told me that they are very small and that I shouldnt be concerned about it.  ALso I had mentioned it to my surgeon in January and he said that they could be enlarged for a number of reasons including allergies. He wasnt concerned either. I am lost. You believe it needs to be examined. Why wouldn't they? Of course I didnt have an EMG at the time. I suggessted to my internist that is it possible that this burning pain could be fibromyalgia. He said it is possible but I need to get worked up by a rheumatologist. SO it's not like I haven't mentioned these concerns to them. They tell me not to worry about it. I dont know anymore. I am frustrated.
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Hello again,

I just wanted to mention something else. Back when these symptoms started which was 6 weeks after surgery, my surgeon did mention something called RSD and he referred me to a pain managment doctor for a procedure called a stellate ganglion block but the pain managment doctor didnt want to do it. So he referred me to a neurologist and he didnt do anything but put me on a medicine that gave me horrible side effects which I wasnt on for a long time. I then sought out another neurlogist who is baffled. Do you think my surgeon was on the right track. DO you think it is possible it could be RSD since it can spread to other parts of the body? I am just trying to find answers thats all. Thank you
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368886_tn?1278962315
Hi.

As far as the lymph nodes are concerned, were you advised by any of your treating doctors to get any MRI of the abdomen? And do you have any lymph nodes in axilla? Since lymph node enlargement has probably the most extensive list of differentials, it becomes important to screen other parts for lymphadenopathy.

RSD can be one of the differentials, as it has appeared after a few weeks after the surgery. Unfortunately there are no confirmatory tests for RSD. And once again, it will be your spinal surgeon or the neurologist who have to diagnose it. Have you tried any corticosteroids? How was the response?

I would think of getting the biopsy of the lymph nodes and be done with it. Then a trial of RSD treatment. Since the EMG (and I suppose, nerve conduction study, as well) is normal, I would think of an inflammation or a local autoimmune response. The inflammation need not be of infective etiology, as the C reactive protein is normal, and I suppose you sedimentation rate is also going down.

This is a complex picture. It has to have a solution. How's your burning sensation today ?

Regards
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I know. I guess I am complex and have all the doctors baffled. BUt let me reiterate to you that these symptoms began approximately 6 weeks after surgey so I guess thats why it makes being treated difficult as far as diagnosis goes. I am so frustrated. Some  of these doctors must think I am a hypochondriac or something. I know I am not. I have good days and bad days. If I dont have neck pain, I have back pain and vice versa. The burning pain comes and goes. I dont have any burning today. I did have some a little yesterday but it isnt as intense as it was. By that I mean it isn't 24 hours/day like it used to be.  I have not had another sed rate drawn since Jan. I just saw my primary care doctor and he wants me to bring my last MRI film to his office so he can have a radilogist look at it. HE says this isnt his specialty. So I will bring the film to his office on Wednesday and I will have a chem panel drawn. This is something completely different. I have an overactive bladder and he wants to check my kidneys again and do a urinalysis.  No doctor has mentioned a MRI of abd to me.  I feel like the doctors somehow dont care as long as it isnt happening to them then not to worry. I am just frustrated.  My neurlogist is clueless. She will  not be the one to diagnose my RSD. SHe told me she doesnt know whats wrong and this is out of her specialty. Should I get a referral to a neurosurgeon?  THey haven't ordered any more sed rates. I just dont know.
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Yes, I forgot to mention. I was premedicated with Prednisone prior to the last MRI in 12/07 and it did relieve my pain for a few days. So yes to your question. It did help. I did mention this to the neurologist and my spine surgeon as well.  SHe says to follow up with a rheumatologist and he said prednisone has that effect to relieve pain. He really didnt say much. I dont know anymore. I havent given up. Each time I try, it seems I am going in circles. I am tired of going in circles. I just want some answers as to what is going on.  I know my body. THanks again
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sorry bumping up..
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Dr Abhijeet has replied to your questions 10 times total on this post, the other 31 was your posts.  I am not saying that you don't have a medical problem, but he is a busy man and there are alot of people on here with just the same amount of problems as you, if not more.  He is only one person.  Geesh!!!
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368886_tn?1278962315
Hello.

There is no advantage of a neurosurgeon over a neurologist, as far as your symptoms are concerned.

I can understand what you must be feeling now. After having seen so many doctors, you still have no proper diagnosis. Some times it needs just one or two specialists to sit together and discuss the case for the better.

I do not think your urinary frequency is due to any kidney problems. It looks like an autonomic dysfunction.

The decision of biopsy of the nodes will actually depend upon how much of a problem they are to you, as compared to your pains and sensory issues.

Regards
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I want to thank you again for all you the advice you have given me. I believe you are very brilliant and a true caring doctor.  Those are hard to come by. Today my pain has been intense. I have this tearing, ripping pulling pain on the right side of my neck that extends to the posterior skull almost behind the right ear. This has been going on for months but the pain changes. It began to taper off and today it came back with a vengeance.  I have been going in circles with doctors. They are baffled with me.  I dont think I have come across the right doctor yet.  My primary care doctor said the hands arent related to the neck which I beg to differ. Could the plate be causing these symptoms? OR could it be as simple as a hardware issue as far as the screws? Or could it be the cadaver bone they used to fuse be causing this? How am I going to get 2 specialists to sit together. I believe the doctors arent too concerned with the issues I have. I am not giving up. I know what I feel isnt right. One more description of the pain I feel in the neck is "It is like I have a tight ponytail and someone is pulling it real hard and the roots are coming out." IT burns sometimes too, but not everyday like it did. Do you know any good doctors where I live? LOL.. Thanks again for all you do.
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Hi.

If the plate is in place and the MR has confirmed the same, I do not see the plate causing these symptoms. But these are severe symptoms. You could think of the occipital nerve block as a small test just to see if it is the occipital nerves which are causing the trouble.

I know I am only giving hypothetical options which may be possible. But it is so much difficult to diagnose without a clinical examination.

Regards
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Thank you for all your helpful advice.  So you do believe these are severe symptoms? Why can't I convince my doctors of this? Could the surgery have caused something to go haywire with the occipital nerve? Or could it be something entirely different? I have no where else to go. I have seen 2 neurlogists with no luck. Do I need to find another doctor for this problem. I know my body and I have a very high threshold for pain and I know that feeling in my neck isnt right? Would a CT scan show the hardware better than a regular xray? What do you think of a myelogram?  I was supposed to have this a while back but the doctors cancelled it twice on me. SO I just want to know what tests can better diagnose this problem I have been having for some time? And why would my sed rate be elevated on 2 different occasions? Is that significant? DO you know any good doctors in Texas/?  Sorry for all the questions..I just want to find out what is going on with my body.I know you are a very caring doctor. THanks again
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I just got off the phone with my internal medicine who I saw on Monday. He asked a radioligist to look over my last MRI that I had with the enlarged lymph nodes. He said it looked good as far as histology goes and that it was probably nothing. My doctor did say he suggessted a CT scan to look at a further but didnt mention getting a biopsy.  So I told him that a CT scan was fine. He also sad my chem panel looked good and my urinalysis was normal. I knew I had no problems with my kidneys. He gave me a urologists name to follow up with that. My question to you is, Will this CT scan I get of the lymph nodes show bones as well? I hope so, for my sake. I could also see if I am 100percent fused. I just wish I could figure out what this pain is.  SOrry to ask so many questions. Thanks again for all you do..
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Hello.

It will depend on the angle at which they capture the lymph nodes. If the concentrate only on the lymph nodes, you may not get a clear picture of the cervical vertebrae.

Can you not ask them to include the cervical spine as well?

Regards
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Well, I guess I could ask. I hope he would do that for me.  I will try calling his office on Monday.. Also, I still dont get what causes this burning pain in the right side of the neck and also that tearing ripping pulling pain I get sometimes. I still dont understand why the MRI's arent showing anything that is wrong. Isnt it true that MRI's can miss some things at times, and would a myleogram be a better diagnostic tool in finding something.? I am trying to get in to see another surgeon to get a 2nd opinion. I hope I get that 2nd opinion b/c I sure do need one here.... Dr. Abhijeet, are you a neurosurgeon? I am just curious? Thanks again for all your advice..I believe you have better angles and are more brilliant than what I have been running into.
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Hi.

I am not a neurosurgeon. A myelogram would be an additional investigation. We can't right away that it will give us any additional information. As I has mentioned earlier, I do feel this is a neuropathic pain. It may turn out to be something different. The other possibilities are neuromuscular problems.

Regards
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HEllo again. What tests should I have to figure out what is going on. I feel like I am going nowhere with the doctors I am seeing. THats why I am trying to get a second opinion at the med school here.  I should hear something by Wednesday.  What type of neuromuscular problems are you referring to??  What do you think my next step should be?  Do you think the disc at c7-t1 is causing some of these problems since that one is herniated but not pressing on the spinal cord. My doctor didnt operate on that one.? I just dont know. I am not giving up until I have a diagnosis.  Please advise. THanks
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Hi.

I think you should rule out extra disc bulging. The disc need not press on the cord to produce symptoms. The nerve roots may also get affected.

I would say a detailed EMG for the C7-T1 disc is needed. And I suspect it to be abnormal. Can't think of any other test at the moment.

Regards

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I have already had an EMG. Do you want me to type the report for you? Would the disc at C7 T1 be causing all the pain I am having in the neck and thoracic back area? I have quite a bit of upper back pain all the time. If it isnt the neck hurting it is the back hurting.  I dont think I could get another EMG at this time since I just had one done. Thanks again
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Hi.

Yes, I do recall about your EMG. And I suspect it was normal. That's why we are not sure how this pain could be due to nerve impingement. I won't ask you for another EMG now.

What is the progress about the lymph nodes? Are there any indications from the doctors about the biopsy? FNAC is quite safe.

The nerves from the C7 - T1 do supply the neck and upper shoulder area. We have all the reasons to believe that the pain is originating from this segment.

Regards

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As far as the lymph nodes. THey are not suggesting a biopsy. My primary care doctor discussed with a radiologist. HE said if i wanted to I could get a CT scan of that area if I was concerned.  So I dont know.. THank you
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Hello again. Well I got a call from the CT scan place b/c my primary doctor ordered a CT scan of the neoneck of just my lymph. So I asked the scheduler to call his office to see if they could add it of my c-spine too. HE didnt want to order. I figured with all the complications I am having, that it wouldnt be a bad idea to get this done as well so I wont have to another one later on down the line. I guess I need to contact my surgeon to get this ordered so I can get both done at the same time. I am so frustrated. I am getting nowhere with these doctors. Now do you understand why I want a second opinion preferrably from a neurosurgeon. I just dont know anymore. I do know that there is something wrong in my neck on the right side and I am not GIVING up.... I just wish these doctors would be more proactive in my situation.  
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Hello again.  I am going to have the CT scan of both the spine and the lymph nodes.  I am having a very hard time getting a 2nd opinion. IT seems since I have had the surgery no doctor wants to give me a second opinion.  I made an appt with my surgeon for April. DO you have any suggestions of what I can ask him so I am not ignored.?? If I am not having neck pain I am having upper and mid back pain. Please advise... thank you
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Hi.

It is good to know that you are getting both the areas scanned. The main focus should be on the neck spine. I guess your query should be about pain and symptoms relief after ACDF surgery.

The surgery probably has led to more nerve entrapment. Let us hope hte CT scan helps.

Regards
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HEllo,

I am going to have my ct scan next week. My question to you, if they do it with contrast is it the same as MRI contrast. I am allergic to Gadolinium. As far as I know I dont think they are the same. Also do you have any important questions I may ask my surgeon in April. I just need some help. I am having a hard time getting a 2nd opinion and I want some answers thats all. THanks
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Hi.

How are you doing? I will be waiting for your CT scan report.

Traditionally, the CT scan is known to identify bony abnormalities and tumors very well. With the contrast coming into picture, soft tissue abnormalities are also identified. Due to the basic difference in the technologies used in CT and MRI, the MRI is more sensitive and in certain cases, more specific than the CT. This is true with the contrast, too.

We are trying to figure out the nature of the lymph nodes and any possible compressed nerve. MRI with contrast would have been a better choice. But that does not deem the CT scan any less important. In fact, for lymph node diagnoses, CT scan is preferred by many. The CT scan can pick up if there is any calcification in the nodes. If they decide to do a biopsy during the procedure, a CT is preferred.

Let me know.

Regards
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Dr Abhijeet,

I think I may have figured out what may be wrong. IT might be a possibility.  Approximately 4 weeks after my surgery I developed a rash that was on my buttocks and inner thighs and I believe my arms. It was so long ago that I am not sure the exact description. When I had my 4 week follow up with the PA the surgeons assistant I informed her of this. SHe took me off of SOma thinking this was the cause of the rash. That was a new medication that I started. But I didnt think that this was the cause. I stopped taking it but have taken it about a month ago and did fine so this wasnt the cause of the rash. WHen I had the rash I was itching intensely. I did go to a dermatologist and he did prescribe something but it went away. Now this intense burning pain I felt in the right side of my neck started approximately 6 weeks after the surgery and it went on for a long time. Then it spread around my back and under my breasts and in my arms. I believe that I could be having symptoms of Shingles.. The only reason I am saying this is I researched it and have some of the symptoms. It started on one side of my body my neck and it spread. And even wind blowing on that side was intense and clothes on that side aggravated it. IT was like the slightest touch or wind made it more pronounced. Do you think this is a possibilty and how do I go about diagnosing it?? I am so frustrated. I am just trying to figure what is going on. Does shingles cause red hands at times? Thanks
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Hello.

Shingles should have a characteristic rash on the skin. It spreads in a dermatome pattern. If you have rash, you can think of shingles. (Shingles can come without a rash, too.)

For a diagnosis, you can just visit your physician and ask for certain lab tests for Shingles. Tzanck's smear, VZV-specific IgM antibody test and PCR for VZV virus can be done.

Regards
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Dr Abhijeet,

I had an MRI of my thoracic and lumbar back in NOvember. I have a question about one of the results.  On L5-S1 this is what it says:  THe disc is of normal height.  IT is markedly dessicated.  There is a posterior central annular fissure and tiny subligamentous disc protrusion. The spinal canal and neural foramina are widely patent.  The facet joints are unremarkable. There is no evidence of nerve root compromise at this level.  COnclusions:  Small posterior central annular fissure, L5-S1 with small subligamentous disc protrusion.  The lumbar spinal canal and neural foramina remain widely patent at all levels. What does this exactly mean?  And would this be causing my frequent urination??  Is this a serious problem?? Thanks
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Hi.

The spinal canal is the lumen of the spinal cord. It has the cerebrospinal fluid circulating in it.

Neural foramina are the spaces between two vertebrae, from which the nerve roots) coming out from the cord) exit. This neural foramen is formed by the projections of the bony vertebrae. If the disc flattens out, the two vertebrae come closer to each other and the foramen becomes smaller, compressing the nerve root.

You can see these two images for the foramen and the nerve roots exiting from them.

http://www.accuspinadenver.com/images/foramen.jpg
http://www2.aaos.org/aaos/archives/bulletin/aug04/code-1.gif

Your MRI does not show a nerve root compression.

The intervertebral disc is made of two parts, the inner “nucleus pulposus” and the outer “annulus fibrosus”.

http://www.spineuniverse.com/displaygraphic.php/149/invert_disc-BB.jpg

If there is a break in the Annulus (read annular fissure), the nucleus inside tends to come out and press upon the cord.

http://www.ncpainmanagement.com/InfoLumbarDiscography_files/image006.jpg

Overall, the MRI report does suggest a disc problem, but it has not affected the nerves. Any changes since the MRI?

Regards
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Dr Abhijeet,


Hello, how are you? I am doing okay just that I am in alot of pain these days. I had my CT scan today with IV contrast. THey did it of the Cspine and neck including lymph. I won't know my results for 48 hrs probably... I am just having so much upper back pain and its so hard on me.  Do you think it could be failed cervical surgery syndrome??? I just want some answers thats all I want.  I see my surgeon next Tuesday and I have so many questions for him.   DO you have any suggesstions that I may ask for him??  I am so tired of being in pain.. Talk to you soon.. THank you
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Hello.

I won't say the surgery might have failed. But the pain could very well be originating from the same vertebrae on which surgery was done. There is a referred pain which can originate at the vertebrae and the disc. This is not a commonly diagnosed pain. The sensory fibers from the vertebrae and the disc, travel along with and end into the same area where those from the shoulder and upper limb end. The brain interprets the pain as coming from the shoulder, arm, etc. This is referred pain.

Might be a good idea to talk to the surgeon about this.

Regards
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Hello again..
I just got my results of my CT scan...Here it is:

CT scan of the neck with IV contrast, Ct scan of the cervical spine with IV Contrast.

History: neck pain, prior cervical spinal fusion, history of enlarged cervical lymph nodes.
Technique:  Ct scan of teh neck performed with IV contrast. Reconstructions of the Ct scan of the cervical spine performed with IV contrast. Multiplanar reformats.
Findings:
Neck Ct: No lymphadenopathy in the neck. A few scattered normal size lymph nodes noted in the neck with the larger lymph node in the right jugular digastric lymph region measuring 1.1cm, image 56.

Great vessels of the neck are patent.

The pharynx, larynx, and oral cavity appear normal.

Paranasas sinuses are clear. Visualized temporal bones are unremarkable.

Impression
No cervical lymphadenopathy.

Ct scan of the cervical spine:

Anterior plate and screw fixation and discectomy noted C5-C7.
The alignment of the cervical spine is normal.  Vertebral body heights are preserved.
At c2-c3, no disc bulge, disc herniation or significant stenosis.
At c3-C4, no disc bulge, disc herniation or significant stenosis.
At c4-C5, no disc bulge, disc herniation or significant stenosis.
At c5-c6, no recurrent disc herniation. NO foraminal or spinal canal stenosis.
At c6-C7, no recurrent disc herniation. No spinal canal or foraminal stenosis.
At c7-T1, no disc bulge or disc herniation or significant stenosis.
Impression: No evidence of recurrent disc herniation or significant stenosis.

My question to you is: Why would it say at c5-c6 and c6-c7 no recurrent disc herniation. Those were removed so I shouldnt have a disc at these  levels??  What is your impression of this and the lymph nodes? Do you think that the pain I am experiencing could be RSD or shingles?? ANy suggesstions what to do next to determine the cause of all the pain I have and the red hands I get intermittently.  Thank you again for everything.
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Hi.

Even I was wondering about the meaning of that particular sentence. Is it possible that the radiologist was not informed about your history of the surgery? Such a thing usually does not happen.

Since the CT scan report no lymph node pathology, one has to believe that the lymph node have probably got no connection with the pain.

The suspicion is on the referred pain. This can be actually checked with nerve block. When do you have your next appointment with the neurologist?
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Dr Abhijeet,

Yes the radiologist was informed of my surgery. It was even on the paperwork I had to fill out for them so HE made a mistake....I dont know what to think about that one...I dont have an appt with my neurologist...I have an appt with my surgeon on TUesday at 445pm and the rheumatologist on the 29th of APril.  What type of nerve block are you suggessting?  I was going to ask my surgeon to refer me to a pain managment doctor?? I have been having alot of burning pain lately. It worries me but I try and keep a strong positive attitude that it is going to get better. The burning pain I have been having has been in the right side of my neck, under my breasts across the upper waist and my right arm and hands..Hands sometimes sting.. The pain has been constant for the last 3 weeks.. THis burning pain started 6 weeks after the surgery and it slowed a bit down in January and now it is back with a vengence..  Thanks again for your advice..
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Hello.

I am referring to a regional analgesia where the anaesthetic agent blocks the nerve. This is just a thought though. I have no experience of trying a nerve block, to be honest. Please communicate this idea to your pain management specialist.

I guess the basic thought should be to identify the root cause of the pain. There are a few reports of post acdf surgery pain. The pain and burning seems to span over more than one spinal segments.

Regards
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Well, hello doctor.  I saw my surgeon yesterday.. Here it goes. HE says there is nothing wrong with my MRI"s and my CT scan.. He says everything looks good and he doesnt know why I am having all this pain. He did say it is a possiblity of RSD..but that usually starts in arms or legs. He referred me to a pain management doctor and also a neurosurgeon.. He is referring me to someone he knows.. He doesnt know why I am in so much pain. He just says that I had a very large disc herniation rupture and it was impingeing on the cord and that it may get better and may not. It was a bad case. I am atypical.. SO what else. THe problem is everyone knows him and he is very well known in this town.. I know what I am feeling isnt normal.. Yesterday my pain was bad.. TOday a little better.  SO I guess the next step is for the pain management doctor and to talk to this neurosurgeon.. Since they know each other, I probably wont get anything out of it.. We will see... What do you think about getting a block?? What are the risks?.. I just want some answers....Please help me Doctor Abhijeet...
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Hi.

A spinal epidural block is an option which will give a temporary relief. If it works for you, you might go ahead with regular blocks. There are a few side effects from it, though. The site if injection is usually inflamed for a couple of days. You may feel a local pain in the area. The block should be performed by an experienced person.

The pain management specialist should be able to provide you with the available options. Ask about the advantages and disadvantages of different options. I would suggest you to write down your symptoms in a chronological order, as they appeared, and take the note to the doctor. Offer him the written history if he would like to read. Generally doctors don't read it in the office hours or when a patient is in the office. He may read it later.

Spinal epidural injection is an option you can try.

Regards
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Dr Abhijeet,

Hello again.. I still think there is something that my surgeon is missing. I believe that it is either referred pain like you said from the neck down to my back or something... THe right side of my neck feels like a pulling sensation, sometimes tearing. I have chronic upper back pain that is intractable.  I just dont understand why I cant get any answers from my surgeon... I just want to find one doctor who will listen to me.. Do you think it could be a screw that isnt in right that could be pulling... I asked my surgeon about scar tissue after the surgery and he said "not really." He also said it couldnt be possible that it is referred pain.. Why is it that some doctors think they are perfect and that a mistake couldnt have happened? I am not looking for trouble, I just want answers. I am tired of being in pain.. Will a CT scan show my screws??  I am still waiting for my surgeons office to send my paperwork to the pain managment doctor. I found a doctor on my own for a second opinion. The problem is like I told you before, everyone knows my surgeon..I am not giving up... You have any suggestions? Thank you again
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Hello.

The chances of a hardware problem are very low, as the earlier CT scans have ruled out any problems. The screws are fixed during the operation and an internal fixating cervical plate is inserted to give the hardware additional support. With this much precaution, I do not think the problems you are having are due to the screws coming out.

It seems no one has answers for your pain. Have you been taking any physical therapy? How about the neck muscles? Are they unusually stiff?

Regards
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HEllo again.  I stopped Physical Therapy months ago... I believe in December.  My neck muscles do feel tight as well as the upper shoulders too.. I am hurting all the time.  Do you think I could be rejecting the cadaver bone?? What are the symptoms and how do you know if you are?? Are there any tests to determine this?  I see the Rheumatologist in April 29th and a neurosurgeon who treats spine in 2 weeks. Thank you
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Dr Abhijeet,

Please help me understand.. I talked with the radiologist yesterday that read my Ct report b/c I wanted to clarify the conflicting report and stories I have been told. When I saw my surgeon last week, he said everything looked good on the CT scan and that I am fused.  I asked him about the report saying "no recurrent disc herniation at C5-C6 and no recurrent disc herniation at C6-C7."  His PA said that it was ligaments. And I asked why would the radiologist report that.. I also asked him if I had any scar tissue at any of those levels and he said "no, not really."  I am so upset.  I cant get a straight answer from anyone.  So I called the radiologist that read the report and he said what he meant by that sentence was I have no stenosis or narrowing at those levels. He also said he saw entire bone at C5-C6 and C6-C7 was 90 percent solidly bone. He said there is a little that isnt bone at that level and that I have normal scar tissue but nothing causing narrowing. My surgeon didnt even inform me of this scar tissue and that I am not 100 percent fused at c6-c7.  I just dont know anymore. I am in constant agonizing pain but I cant give up. What is your impression.. Is it normal not to be 100 percent fused. I have an appt to see a 2nd opinion with a neurosurgeon next week.  I am just so upset, I want answers. All I want is someone to be honest with me and help me..I also see the pain managemnt doctor in 2 weeks..for evaluation.. What is your opinion Dr Abhijeet....?  THanks again for your advice....
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Hi.

"Could this be pseudoarthrosis?" is the question now. When the vertebrae are intended to fuse, but do not do so, they are still mobile to a small extent. This is called pseudoarthrosis (false joint). A pseudoarthrosis makes the spine unstable.

Often the neurological examination is normal in a pseudoarthrosis. A revision surgery can be done to correct the pseudoarthrosis and fuse the vertebrae again.

Regards
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Hello again..

I am so appreciative of your knowledge. I know there is something wrong and I cant get my surgeon to be honest with me. He is a highly respected physician here and everyone I speak to in the medical profession knows him.. I am not looking for any trouble, I just want to find out the cause of my pain.  My question to you is,  How can this pseudoarthrosis be diagnosed. What tests need to be run in order to diagnose it? Please help.. I have an appt with a 2nd opinion with a neurosurgeon next Friday.. I would kindly appreciate any information you can give me.. Also how does pseudoarthrosis happen?  Is it because I used a cadaver bone?? I am just searching for answers DR Abhijeet.. THank you..
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Dr Abhijeet,

Hello again.. I wish I could send you the Ct scan report. Well anyways,  I looked at the CD for the first time today. I wanted to find the area that wasnt completely fused and I found it.. It is clearly noticable on the Ct scan report. It is on the right side of the neck where I am having all my problems.. What are the chances of it fusing completely?. I saw where it is not connected at all.. Do I still have hope for it to fuse?  I never had left sided neck pain before or after the surgery.. The intense burning pain started 6 weeks after the surgery and that was probably when I was trying to fuse. What are the symtoms (symptoms) of pseudoarthrosis?  Is revision surgery the only option to fix the problem? And is 90 percent fusion not good and would this be causing all the pain...Please let me know what you think before I see the new doctor on Friday... Thank you again.
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Hello.

Sorry for the delay in responding. Symptoms of pseudoarthrosis can be the same as those before surgery.

N. Mutoh et al observed that ".....Symptoms resulted from abnormal mobility, cord compression due to posterior slip or rotation of the upper vertebral body, kyphotic deformity or a problem at the adjacent level........." This suggests why pseudoarthrosis produces symptoms.

There is a very good article on pseudoarthrosis. The link is as follows-
http://www.medscape.com/viewarticle/448387_4

The article mentions the need to identify the pseudoarthrosis. Of particular relevance is this extract,"......... In patients with recurrent or persistent neck pain, however, pseudoarthrosis should be considered as a likely etiology..........."

There is also a good article on how pseudoarthrosis due to ACDF can be managed. The link is - http://www.ncbi.nlm.nih.gov/pubmed/1440001

It mentions a need for a posterior approach surgery to manage pseudoarthrosis secondary to ACDF.

In your case, pseudoarthrosis may be present. Try to get the CT scan reviewed for this purpose again.

Regards
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Dr Abhijeet,

Hello again.. I called my surgeons office and spoke to his PA, his assistant. They still are saying I am fused...Why would the radiologist say I am only 90 percent fused? My surgeons assistant tells me not to listen to him and that he is not a neck surgeon. I feel like I am being medically neglected on my surgeons side. They refuse to listen to my symptoms and tell me that the radilogist is wrong... I have seeked a 2nd opinion for Friday with a neurosurgeon.. Will he be able to tell if I am fused from my CD?  I am so frustrated.. I want to get to the bottom of this.. If I am only 90 percent fused like the radioligist said if that is true, do I still have time to fuse completely/??  I really dont want to have a 2nd surgery.. And why would one vertebrae fuse and not the other?? Do you have any suggestions I might ask the neurosurgeon..? I also see the pain management doctor next week....for an evaluation.. Thanks again.
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Dr Abhijeet,

I saw the neurosurgeon yesterday... Didnt go that well. He of couse knows my surgeon.  Anyways, the good news is from his standpoint I am fused...So, he suggests I go to the pain management doctor that my surgeon referred me to and have some type of block whether it be a facet block, stellate ganglion block or an ESI.. SO that was about it.. I asked him about the red hands bilaterally and he said RSD doesnt usually manifest it bilaterally that it is usually one sided.. The only thing I got out of the visit that is I am fused and that was it... A waste of money on the insurance part.. I just wanted an honest unbiased second opinion and he knew my surgeon... Oh well... I guess I will see the pain doctor and hopefully something will be figured out...
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Instead of consuming all of Dr. Abhijeet's time with your endless questions that are essentially the same thing over and over again, why don't you find another Dr to go see?  I can tell that you would like Dr. Abhijeet to be your doctor, but he can't.  He also can't diagnose you online.  Go to another part of your state to see someone if you are that concerned about the care or lack of care that you are getting from your current doctor.  I know that sounds harsh, but this is a place for "advice."  You have to get your care somewhere else.  I have been searching for a diagnosis for many years now- keep trying- you'll eventually find someone who will help you.    
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This is probably why Dr Abhijeet isn't posting anymore.  I too suffer from burning pain, but it is everywhere in my body.  I am now finally after 7 years getting help, from one doctor to the next.  Thank you jmanderson, you took the words right out of my mouth.
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63 posts, I'm sure that can't be good on your neck.
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368886_tn?1278962315
Hello.


I hope you are still on the forum. How did your visit with the pain management doctor go? I would agree with the neurosurgeon about the possibility of RSD. But one really has to examine the patient before ruling RSD out.


Regards
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368886_tn?1278962315
Hi.

How are you? Are you still there on this forum? I have been checking this thread off and on. Is there any progress?

Regards

Abhijeet Deshmukh, MD
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Dr Abhijeet,

HEllo.. I just thought I would check this site today and I am so pleased I saw your post.I am getting worse.. I have multiple symptoms still and still very few answers.. I dont know where to turn anymore.. I did see a Rheumatologist and had a complete workup..HE thinks I have an undifferntiated spondylarthropy seronegative RA.. but I feel that is not what I have.. He wanted me to start taking Plaquenil but havent until I get another opinion.. I know what is going on with my body and have done so much research.... It is all stemming from my neck and I believe I have nerve damage in my CSpine that is wreaking havoc on my body and my  circulation.. I was sick about 2 weeks ago with a sore throat and swollen lymph nodes and a PA put me on Keflex 2000mg a day for 10 days.. 3 days into the antibiotics my burning neck pain was relieved and my red hands were not inflammed anymore.. I think this is significant..Also when I had those MRI's and mylegram last year I was premedicated with steroids and that helped too.. SO I have multiple things not a clear picture for the docors.. I believe I have some type of brachial plexus injury or nerve damage in the neck...I also have inflammation chronic and not sure what that is.. I did find out my Vit D level was real low and I am on 50,000 Units a week for 3 months.. I have 3 weeks left of that. I was also started on Fortical for osteopenia.. I am so stressed..that no one can figure out was is going on...NOw my right eye is drooping where I have all that neck pain and I am scared.. I have that terrible right side neck pain that radiates up to my skull on the right side and my scalp is tender on that side... I have pain behind my right eye and my eye is drooping a bit... I just am so worried and I cant seem to find anyone who cares.. I am having trouble sleeping too and this has been going on for a long time b/c I am in chronic pain...My sed rate was 31 the last time they checked.. I tested positive for Sgogrens syndrome too in my blood.. SSA I believe.. My primary care doctor had blood cultures drawn on me recently but dont have those results yet.. My antibiotics were complete on a Thursday and they were drawn on a Tuesday so I dont know if that would interfere with the results.. I think there is something that dr's are missing.. I am very fatigued so fatigued that I have no energy to do much..
What are your opinionss? Do you have any suggestions..?
My hands started turning red and inflammed again.. and it was weird that the short time I was on Keflex my hands werent red.. I hope there is no infection deep in my cervical spine that they arent catching or something left in my neck like a sponge.. I just dont know what to do.... Please help me Doctor. I am so happy I decided to look at this website and you showed your concern for me.. I really want to thank you for that..

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Hello.

Nice to see you are back on the forum. I am sorry you are still not able to get your symptoms under control.

I can not comment on the RA, but I do agree that there is some residual nerve compression in the cervical cord.

There are various tests to find out if there is any infection. I guess you can ask for those.

It is really difficult to find out one common thread to all the symptoms you have been experiencing for such a long time.

Hope your eye problem hasn't increased.

Abhijeet Deshmukh, MD
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Hello again,

I just wanted to post something they found out.. I had a WBC scan and a Spect Bone scan and they found activity at C6-C7.. THe new doctor I am seeing believes  I am not fused at that level and possible infection at that level even though infection didnt show up there. I have all the inflammatory markers. He recommends a revision surgery but with risks.. My bone could be infected in my spine. He recommends I go out of state and with a surgeon who has done alot of revisions since my case is complicated.. How can so many doctors I have come across miss this diagnosis.. after all the scans and xrays I have had.. I just dont understand it.. Do you have an email I can send u some information to? Please Dr Abhijeet, now that i have nonunion at C6_C7 would this be contributing to all my pain in my neck and shoulders? I just dont know.. My surgeon always told me I was fused and not infected.. I asked my original surgeon several times this question..Please give me advice..Thank you
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Hello.

Hope you have some relief from the pain as you read this.

There has been some good reasearch on post - ACDF non fusions. One of the studies, done on a series of 19 patients with non-unions suggests a revision surgery with allografts from Iliac crest has 100% success. (Coric D et al, Journal of Neurosurgery, 1997)

In this series, they had diagnosed non-union with SPECT bone scans, which "....has the potential to reliably confirm the diagnosis of pseudarthrosis." (Abstract)

One more study suggests a 'posterior' cervical fusion is more beneficial than a repeat anterior fusion. (L. Carreon, The spine Journal)

Your SPECT reports do hint stringly towards non-union. In my opinion, you should approach this issue as a non-union and see the other surgeon suggested by your current surgeon. You can mention to him/her about these two evidences / approaches to non-union.

I can not comment upon the possibility of infection here. I hope your surgeon will figure it out soon. But the infection has to be treated sooner than later, as it may not allow for a corrective surgery.

I can understand you have to suffer from the constant pain. I think you can go ahead and see the other surgeon.

Regards,

Abhijeet Deshmukh, MD
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Hello Marisa.

I am sorry for the late reply.

I don't think 'number of surgeries' is the only criterion for a surgeon to be good. But I guess, like any research trial, the doctor should have done a sizable number of surgeries.

In my opinion, you should see a Spine surgeon. An added neurosurgeon will be a bonus. But the two surgeons should be able to discuss your case and reach a goal together.

The problem of missing the non-union/malunion (or any other post-surgical complications) is quite universal. That doesn't mean they are not good doctors. It's just that there may not be a proper communication among all the specialists you have seen. And by the word 'communication' , I mean everything including phone conversations, notes, etc. If you have a case manager (a doctor who oversees all your investigations and progress), the process becomes well directed.

The WBS scan may also suggest inflammation, if not infection. A long standing non-union is bound to produces inflammatory markers.

I am not an expert on the subject, but in my opinion, you should consider a revision surgery. And please do consider your own graft. It's always better than any other. A posterior revision surgery is found to be beneficial. If you were to construct a decision tree, you would always have better prognosis with a spine surgeon's consultation, and perhaps a revision surgery. (taking into consideration the risks / possible side effects of a revision surgery).

Please let me know what you decide.

Regards

Abhijeet Deshmukh, MD
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