Cervical stenosis: Leg weakness

Well, here is what today's cervical MRI showed. Although, I am still working my way through what this all means but it seems like I have vertebrae sliding in both directions?

" Straightening of the cervical spine. C4-C6 ACDF which appears
intact and well-seated. Grade 1 anterolisthesis of C2 and C3 and C3 and C4.
Grade 1 retrolisthesis of C6 on C7 disc space narrowing at the C6-7
transitional level with endplate sclerosis and ventral osteophytosis.
Diffuse facet arthropathy uncovertebral hypertrophy.
Flexion/extension views demonstrate no evidence of instability"

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Sorry, the previous was the regular xray to check for the listhesis. Here is the MRI summary in case anyone has any input on what this all means:
C2-C3: Facet arthropathy, mild ligamentum flavum thickening uncovertebral
hypertrophy and disc osteophyte complex with mild-to-moderate canal
narrowing. There is mild-to-moderate left foraminal narrowing..

C3-C4: Facet arthropathy, right greater than left, uncovertebral hypertrophy,
and disc osteophyte complex abutting and-or minimally flatten the ventral
cord with mild-to-moderate canal narrowing. Mild-to-moderate left foraminal
narrowing

C4-C5: Facet arthropathy uncovertebral hypertrophy and posterior osteophytic
ridging with mild right and mild-to-moderate left foraminal narrowing..
C5-C6: Facet arthropathy uncovertebral hypertrophy posterior osteophytic
ridging without significant stenosis..
C6-C7: Facet arthropathy, ligamentum flavum thickening, uncovertebral
hypertrophy, and disc osteophyte complex with mild-to-moderate canal
narrowing. Suggestion of moderate bilateral foraminal narrowing..
C7-T1: Facet arthropathy uncovertebral hypertrophy and disc osteophyte
complex without significant canal stenosis. Moderate right and
moderate-to-severe left foraminal narrowing..

IMPRESSION:

1. C4-C6 ACDF which appears well incorporated. Spondylosis most pronounced
at the C3-C4 and C6-7 transitional levels with mild-to-moderate canal
narrowing at these two aforementioned levels.
2. Moderate right and moderate-to-severe left foraminal narrowing at C7-T1.
3. There is suggestion of moderate bilateral foraminal narrowing at C6-7.

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@cudabinacontenda I can tell you from experience that the spinal cord does not want to be touched at all. When you have an existing disc and bone spur complex in the central canal, it can be raking across the spinal cord when you move your neck. When you add muscle spasms that happen with spine problems, it can be moving the vertebrae around and affecting alignment or rotating them and that can increase pressure on a place that is getting touched by essentially making the spinal canal a bit "smaller". That was happening to me, and I had vertigo because of it. Spasms can stretch the vertebral arteries that run inside the sides of the cervical vertebrae and then a movement like looking upward kinks a stretched artery. This is part of the blood supply to the brain. What are the movements you describe that are causing light headedness?

I have to say it makes me crazy to hear of another surgeon telling a patient that leg symptoms are not related to cervical central canal stenosis. I heard this from 5 surgeons, and they were all wrong. It was the 6th surgeon at Mayo who knew that these symptoms of cervical stenosis were related to leg pain, gait disturbances, nausea, vertigo, bladder or bowel disturbances or pain anywhere in the body below the level of compression.

The spinal cord is supposed to be free to move with the spinal canal and floats in spinal fluid. If you bend your neck, the cord needs to move inside to allow that to happen. Imagine a garden hose with a rope inside. Now bend the hose. Did the rope move a little bit? It has to move. If the rope is held tight, it will bind up against the inside of the hose. The bone spurs and bulging or ruptured discs can hold onto the spinal cord and that can be an intermittent problem at first depending on neck and body positions. As that progresses and bone spurs grow bigger and multiply, then the cord can be compressed and unable to move in what they call a tethered cord. Myelopathy (spinal cord damage) may show up as a white mottled area within the spinal cord at the point of compression on an MRI. My surgeon told me that myelopathy can be present when this compression is beginning and not yet show up on the MRI.

This would be something that would be good to discuss with your physical therapist because they understand how the body needs to move and what is normal and what is not. Your PT also has to write notes and reports and send that to the doctor who ordered it, so that should help if the doctor actually reads the notes. Sometimes they do not. You may want to look at my response to @rdflash0788 and look at the medical study link that I shared. You may want to ask if your surgeon thinks your case may be like that one in the literature. This is the literature I found after 5 surgeons refused to help me, and I sent it in to surgeon #6 and wrote a letter saying that this literature seemed to describe my experience. I asked if my case was like this one. I suggest always ASK that as a question so you won't be perceived as pointing out a mistake or telling a doctor how to do his job. A doctor can refuse to help and then you'd be looking for another surgeon for an opinion. That's not a bad idea either because multiple opinions can help you, and you can pose the question about the literature which describes "funicular pain" from the start. That is what I had to do after I'd been dismissed because the surgeon missed this, then I found the answer, and none of my doctors would help me approach the surgeon with this information and point out his mistake. I knew he wouldn't listen to me and that is when I turned to surgeon #6 at Mayo for help. That is the reason I help here on Connect to share this knowledge.

Sometimes bone spur growth can progress rapidly. I saw mine double in the area they covered within 9 months on MRIs. I was also charting my symptoms on body diagrams and dating those, so I knew how fast the symptoms were progressing. That helped me know that I needed help and a time frame, but it also scared surgeon #5 out of helping me because he could not explain the pain symptoms. I had this "funicular pain" which was described at the time as a "rare presentation" of pain related to spinal cord compression.

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I did want to check and see what I could find about this image from the c spine MRI showing places of concern. My neuro indicated he didn't see any compression currently that was concerning. However, it looks to me like if there is any space at those points it is very little. Can symptoms be encountered just by the cord being contacted by the vertebrae or does it need to put significant pressure in order to cause symptoms? Also, with regard to the listhesis above and below the previous fusion, is it possible that the day I had the MRI was a "good" day and shows no major issue but if I overdo something, like yard work or house work, can it shift more that what is showing on the MRI thereby causing issues? Just trying to wrap my head around this while I wait for the obligatory PT that Aetna requires before authorizing surgery.
Thanks in advance for any input!

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@rdflash0788 I do see the places you are concerned about. The circled discs are on the front side of the spinal canal. The dark is your spinal cord and the white space around it is spinal fluid. You can see that in the place between C3 and your fused levels that there is bigger fluid space on the opposite side (back) of the spinal cord. It looks like the cord is indented slightly or is bending around the disc in front, but able to move into the space to the back. At your C6/C7 level adjacent to the fusion, it is harder to tell how much space there is. There may be another slice that shows it more clearly. It does appear that there is compression coming from the back side of the spinal canal. Sometimes the MRI slice isn't lined up exactly parallel to the spine, or if there is any spine side curvature it can be off a bit and looking through the slices can give better information.

My spine imaging showed no white space at all on either side of the cord, although the neurologist said there was a little bit of space. My vertebrae were moving out of alignment by a few millimeters, and when that happened, I did have symptoms with a gait disturbance walking with a limp, and difficulty emptying my bladder. I was working with a physical therapist at the time and she would get the vertebrae realigned properly and it resolved those symptoms until the next time spasms caused vertebrae to shift and rotate and then it reoccurred. It was an intermittent problem for awhile and this is how I knew that the symptoms were related to the spinal cord getting touched or compressed slightly. I did also have pain and tingling that could be anywhere in my body and those issues shifted location when I changed the position of my spine.

Going through PT isn't a bad thing, and it may help by strengthening the core so your spine can be better supported. Insurance often requires PT before they will authorize surgery, so in that sense, it does check a requirement off the list.

In answer to your question, yes listhesis does shift the vertebrae bodies and change the shape inside of the spinal canal which may make it a bit smaller with the vertebrae shifting. Think of it like beads on a string and the beads get pulled out of alignment causing the string to touch the side of the hole inside the bead. The question is how much is it shifting and does the cord touch a disc osteophyte complex that is pushing toward the spinal cord? I know from my experience that my fluid space was gone all around the cord, so a shift of listhesis definitely caused symptoms. There was never any spinal cord damage evident on my MRI which is good. Mine was only one level affected, and yours is a bit more complex with a few levels involved and a prior surgery which can increase the symptoms. Prior to any spine surgery, I got to the point that if I bent my neck forward, I sent an electric shock down my entire body, and then it stopped when I straightened my neck again. That is positive proof of touching and compressing the spinal cord. I had bone spurs there in front that were like a knife edge that the cord was bending around. I didn't have the nerve compression in the foramen (nerve roots) that you have which adds more symptoms that are predicable for the specific nerves involved.

How much physical therapy will you be doing? Do you follow up with the surgeon after that? Are you considering other surgical opinions? You've been through cervical spine surgery before, so you must have a sense of what surgery will be like although with adding more fusions, there will be further loss of movement. Did your surgeon discuss other non fusion procedures such as a laminectomy? That would just add more space to the spinal canal. Artificial discs may not be approved for use next to an existing fusion, but that may be something to ask. It is a big decision.

Jennifer

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How did the PT clear it up?

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Jennifer,
Thanks for your quick response and thorough explanation. I go for at least 6 weeks of PT and then F/U with neuro on March 1 to discuss whether it has helped any. If not then he is recommending ACDF of C3-C4 and C6 - C7. That will have me fused all the way from C3 - C7. 🙁
He did discuss that I'd be a good candidate for a hybrid surgery involving an artificial disk but that most insurance companies don't authorized those as the "jury is still out" on whether it is any better than a straight up fusion.
As far as ROM, he said I would lose a little more movement of rotation but more noticeably it would affect looking up and looking down most of all.
I may start looking into seeing if Mayo in Jacksonville will have a look at me if I can get Aetna to approve. Not even sure where to begin with that but I guess we'll see if PT helps any. Decisions, decisions, decisions....

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Sorry, the previous was the regular xray to check for the listhesis. Here is the MRI summary in case anyone has any input on what this all means:
C2-C3: Facet arthropathy, mild ligamentum flavum thickening uncovertebral
hypertrophy and disc osteophyte complex with mild-to-moderate canal
narrowing. There is mild-to-moderate left foraminal narrowing..

C3-C4: Facet arthropathy, right greater than left, uncovertebral hypertrophy,
and disc osteophyte complex abutting and-or minimally flatten the ventral
cord with mild-to-moderate canal narrowing. Mild-to-moderate left foraminal
narrowing

C4-C5: Facet arthropathy uncovertebral hypertrophy and posterior osteophytic
ridging with mild right and mild-to-moderate left foraminal narrowing..
C5-C6: Facet arthropathy uncovertebral hypertrophy posterior osteophytic
ridging without significant stenosis..
C6-C7: Facet arthropathy, ligamentum flavum thickening, uncovertebral
hypertrophy, and disc osteophyte complex with mild-to-moderate canal
narrowing. Suggestion of moderate bilateral foraminal narrowing..
C7-T1: Facet arthropathy uncovertebral hypertrophy and disc osteophyte
complex without significant canal stenosis. Moderate right and
moderate-to-severe left foraminal narrowing..

IMPRESSION:

1. C4-C6 ACDF which appears well incorporated. Spondylosis most pronounced
at the C3-C4 and C6-7 transitional levels with mild-to-moderate canal
narrowing at these two aforementioned levels.
2. Moderate right and moderate-to-severe left foraminal narrowing at C7-T1.
3. There is suggestion of moderate bilateral foraminal narrowing at C6-7.

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@rdflash0788 Here is the insurance page for Mayo Jacksonville. (insurance acceptance is different at each campus) I recommend calling the billing department at Mayo to confirm if they are in network for you.
https://www.mayoclinic.org/documents/commercial-insurance-plan-contracts-florida/doc-20203719

If your insurance is accepted, you may use this link to inquire about appointments at any campus.
http://mayocl.in/1mtmR63

Is there a particular surgeon who looks like a good fit for what you need? You can also inquire at Rochester and there are many more spine surgeons there if you are willing to travel. It is worth traveling to get the best surgeon that you can.

Jennifer

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