Dr Abhijeet PLEASe help

[ms38]

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

[Abhijeet Deshmukh, MD]

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

[ms38]

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.

[ms38]

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.

[ms38]

Hello. Dr. Please advise. Thank you

[ms38]

I am just trying to get bumped up so the doctor would respond. Please help. I am so worried.

[ms38]

Dr Abhijeet..Would you please advise..I would kindly appreciate it..Thank you

[Abhijeet Deshmukh, MD]

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

[ms38]

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.

[Abhijeet Deshmukh, MD]

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

[ms38]

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

[ms38]

bumping up.

[ms38]

bumping up

[ms38]

bumping up

[Abhijeet Deshmukh, MD]

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

[ms38]

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..

[ms38]

bumping up

[Abhijeet Deshmukh, MD]

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

[ms38]

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

[ms38]

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

[ms38]

bumping  up

[Abhijeet Deshmukh, MD]

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

[ms38]

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.

[ms38]

bumping up

[Abhijeet Deshmukh, MD]

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