Hi Jules,

I have been really disappointed with them.

My Italian friend Alfred in Italy has been a radiologist for 30 years.
Just recently I have explained to him what has happened to me over the last 8 months via Whatsapp.

He asked me the same question you asked about the EMG.

I have told my pain doctor about doing an EMG. He looked surprised that I asked him such question.
Basically he told me that he will consider it but he has done nothing about this for the last 3 weeks.

I am wearing neck support by my own choosing. The never suggested such a thing.

I have complained many times that I am getting more pain in the neck, followed by some numbness there, in my groin and feet when sitting or lying down.

The question remained unanswered and skipped to his next topic. He has totally disregarded what I asked him.

Summary of has happened so far with my conditions:
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SYNOPSIS
Alfred presents with lower neck pain, in the context of multiple previous road accidents (bicycle vs car in 2013, 2015, 2019). Injuries suffered following 2013 accident include left brachial plexus trauma.
Injuries suffered following 2019 accident include fractured ribs, thoracic transverse processes, superior pubic rami, and inferior pubic rami.
Alfred’s worst pain is lower cervical midline and left-sided neck pain, worsened following August 2022 incident in which he felt his neck “twist and crack” whilst lying on the floor, and again worsened following 28/11/2022 C6 nerve root injection at The Alfred Hospital. The latter injection appears to have been organised after Alfred presented to the Emergency Department with neck pain and altered arm sensation. Since early January 2023, Alfred is reporting intermittent right-sided burning neck pain which sometimes radiates into his right upper limb and hand; central and left-sided neck pain remains predominant. Other associated symptoms include headache, head pressure, dizziness, left ear ache and pulsating, right ear tinnitus, intermittent hand and feet numbness, intermittent left hand pain,
and low back pain.
January 2023 MRI cervical spine reported:
• C3/4 – moderate right neural exit stenosis (contacting right C4).
• C4/5 – moderate left and mild right neural exit stenosis (contacting bilateral C5).
• C5/6 – spondylolisthesis, moderate left and mild right neural exit stenosis (contacting bilateral C6).
• C6/7 – moderate bilateral neural exit stenosis (contacting bilateral C7).
• C7/T1 – mild bilateral neural exit stenosis (contacting bilateral C8).

January 2023 MRI thoracic spine reported:
• Mulitlevel discogenic disease and multilevel facet joint arthropathy.

2022 MRI lumbar spine reported:
• Diffuse spondylosis/degeneration, most significant at L2/3 and L5/S1 levels.
• Multilevel disc-osteophyte complexes resulting in right L2/3, L3/4 and L4/5 foraminal
stenoses.
December 2022 bone scan reported:
• Some increased disc degenerative activity at C5/6 with less-marked disc degenerative activity at C4/5 and to a minimal degree at C6/7.
• No increased cervical facet joint activity; slight increased activity in the left T2/3 facet joint.
• Lumber spine – marked increased disc degenerative activity at L2/3 and L5/S1, slight
increased activity at right L4/5 and left L5/S1 facet joints.
On 05/01/2023, Alfred received left C7/T1 T1/T2 T2/3 facet joint injections – he described 60-80% relief for 1 hour, with return of pain to baseline after 2 hours, then next day 60-80% relief for 24 hours. On 17/02/23, Alfred received left-sided cervicothoracic medial branch blocks (in the region of pain, specific levels TBA) through radiology services – this provided no pain benefit and thus makes facet joint source of pain unlikely.
Alfred previously consulted a spinal surgeon who recommended no role for operative
intervention.
Alfred demonstrates significant anxiety, feeling “on edge”, depression, frustration, and despair which he mainly attributes to worsened pain since August 2022. Domestic stressors include 2 children with special needs. He is currently requiring diazepam prn. I have reiterated the biopsychosocial model of pain and facilitated understanding of the connection between mental health and pain experience. He is working with a psychologist
ANALGESIA
• Diclofenac 50mg nocte
• Endep 10mg nocte
• Pregabalin 75mg nocte – reports causing clamminess.
• Clonidine 50mcg nocte
• Targin 10/5mg nocte prn
• Diazepam prn (for muscle spasms).
Main side-effect reported is constipation.
PROGRESS
Alfred reports ongoing episodic severe pain, most prominently in the left-side of his lower neck. He reports that pain is worse when lying (therefore impairing sleep) and that pressing the region of pain causes radiating pain to shoot down his left leg.
Since last consult, Alfred has received the following imaging:
• 2023 Bone scan – increased activity in left C6/7 and T2/3 and right T5/6 facet joint.

Since last consult, Alfred has received the following injections:
• 17/02/23 Left C6 to T1 medial branch blocks – no benefit.
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MANAGEMENT PLAN
1. I have explained that to date we have not found a convincing biomedical cause of pain, and
thus our dual goals at this point are to continue investigation for causes whilst simultaneously
managing his pain using pharmacological and non-pharmacological techniques.
To this end, Alfred and I have agreed on the following medication changes:
a. Cease Pregabalin.
b. Commence Gabapentin 300mg TDS.
c. Increase Endep to 25mg nocte.
d. Increase Clonidine to 50mcg bd.
e. Commence Orphenadrine to 100mg bd.
f. Change Diclofenac to PRN.

I am totally ignorant about pharmaceuticals but the above looks like a lot and probably will give me side effects like nausea, dry mouth etc. I am particularly worried about Orphenadrine.

As far a new injections go, these are the doctor's recommendations:

Referral for CT guided left C6/7 and left T2/3 facet joint injections with particulate steroid such as cortison.

I know the scenario doesn't look good.

I definitely need surgery such as either fusion, artificial disc replacement or laminoplasty.
Obviously I have to meet certain criteria to be a candidate of any of these interventions.

I agree with you Jules that too much time has gone by and something need to be done.

As I mentioned earlier in my previous posts, I am seeing another neurosurgery group on the 6th of April.

Tomorrow I will be getting a CT Brain/Carotid angiogram with contrast but without a catheter to check my brain and vertebral arteries.

Now I am also getting some numbness going up my back of the head and on top of my scalp which is quite annoying. It come and goes.

I keep praying so that I can get out of this horrible situation. I really need a top neurosurgeon.

Thanks.

Best regards

Alfred

Hi Jules,

How are you?

As of the 6th of April I saw a new pain management doctor.

He is part of a professional team called Precision Health Brain and Spine in Melbourne Aus.

I am looking forward to a new positive start.

The pain has been nagging a bit, but in my mind I told it to go to hell and the less I paid attention to it, the better I felt.

This doesn't fix the problem, but I am managing the pain a bit better by ignoring it. Anxiety has gone down too.

Let's see what these new specialists can do for me.

Best regards

Alfred