Cervical surgery or not: What to do with conflicting recommendations
 

Hi Everyone - Over the past 2 months I've visited 5 orthopedic surgeons related to issues with my neck. I'll describe those exact issues in more detail but the overall takeaway I've learned is that there is little consistency among orthopedic surgeons in treatment and assessment for my particular case.

My current symptoms are daily pain, some intermittent pain in the left thumb, and issues gripping objects with my right hand (feels unsteady and shakes). I've had chronic neck pain for the better part of the past 5-6 years and had an MRI done at the time.

3 surgeons recommend no surgery until my symptoms worsen. Their examples are dropping objects, walking funny, bowel/bladder problems or trouble buttoning. 2 surgeons recommended surgery now to alleviate the spinal cord compression and reduce the risk of paralysis if I was in some sort of traumatic event (ex; car accident). 1 of the surgeons said my myelomalacia was progressing slowly but that differs from what others have said and the MRI report. One of the surgeons said I should get a laminoplasty and to avoid a fusion like the plague. Another surgeon said to get a 2 level disc replacement with 1 level fusion. Another said he'd fuse my entire neck if I needed surgery and another said to just get a 2 disc replacement.

What I was looking for with this post was just some advice from what others have experienced and any recommendations on how to proceed. As it stands right now, I'm 36 with 2 very young kids. Surgery is the last thing I want but if it's necessary, I'll do it. I'm just trying to figure out if it's necessary and what type of surgery to get. I appreciate your time and sorry for the long post.


Here are my issues per my most recent MRI taken in June 2021:

HISTORY: Disease of spinal cord, unspecified. Other specified diseases of spinal cord. Myelomalacia. Spinal stenosis, cervical region. Radiculopathy, cervical region. Patient states chronic intermittent posterior neck pain radiating down into bilateral shoulders for several years.

TECHNIQUE: A 1.5 Tesla system was utilized.

Contrast: The patient was injected with 15 cc out of 15 cc Clariscan single-use vial.

Multiplanar MRI of the cervical spine was performed including T1-weighted and T2-weighted sequences. Images were obtained without and with intravenous contrast.

COMPARISON: MRI cervical spine dated 9/15/2017.

FINDINGS: Cervical alignment is unchanged, without acute fracture or subluxation. There is no significant bone marrow edema or bone marrow signal abnormality.

There is flattening of the cervical spinal cord at a few levels. There is bilateral myelomalacia within the cord at the C4-C5 level, which is unchanged compared to the prior exam. There is no new cord signal abnormality. Limited evaluation of the posterior fossa is unremarkable.

At the C2-C3 level, there is disk desiccation without significant disk bulge. There is no spinal canal or neural foraminal narrowing.

At the C3-C4 level, there is disk desiccation with a disk bulge and right greater than left uncovertebral joint hypertrophy. There is effacement of ventral CSF space with minimal flattening of the ventral spinal cord without significant canal stenosis. There is moderate right neural foraminal narrowing. There is no significant interval change.

At the C4-C5 level, there is disk desiccation with loss of disk height. There is a small disk bulge with mild uncovertebral joint hypertrophy. There is effacement of ventral CSF space with mild flattening of the ventral spinal cord, with borderline narrowing of the spinal canal. There is no significant narrowing of the neural foramina. There is no significant interval change.

At the C5-C6 level, there is disk desiccation with a small disk bulge. There is left uncovertebral joint hypertrophy. There is effacement of ventral CSF space greater towards the left with mild flattening of the left ventral spinal cord and borderline narrowing of the spinal canal. There is at least moderate left greater than right neural foraminal narrowing. There is no significant interval change.

At the C6-C7 level, there is disk desiccation with a small disk bulge. There is effacement of ventral CSF space with mild flattening of the ventral spinal cord. There is mild narrowing of the neural foramina. There is no significant interval change.

At the C7-T1 level, there is no disk bulge. There is no spinal canal or neural foraminal narrowing.

On postcontrast imaging, there is no abnormal enhancement within the cervical spine and cervical spinal cord.

Limited evaluation of the regional soft tissues demonstrates no significant focal abnormality.

IMPRESSION:
1. Multilevel degenerative change within the cervical spine, as described above, with no significant progression since 2017 imaging.
2. Stable bilateral myelomalacia of the cord at the C4-C5 level.

Results of most recent EMG and Neurologist notes taken in June 2021:

36 year old man presents for evaluation of cervical myelopathy with myelomalacia. Examination reveals hyperreflexia and mild weakness and numbness in the left C6 myotome and dermatome. MRI C spine reveals multiple disc herniations with myelomalacia at C4-5, stable over the past 4 years. EMG reveals bilateral chronic C6 radiculopathy as well as left carpal tunnel.

Overall, I suspect his myelomalacia is either traumatic or compressive in nature due to his history of being in a physical altercation in which his head probably hit the floor as well as his multiple disc herniation in his cervical spine superimposed on a congenitally small canal. I do not suspect a neurologic condition such as multiple sclerosis given the symmetric nature of the lesions and the fact that there are no other cervical spine lesions and no other lesion on brain MRI performed in 2017. B12 deficiency, copper deficiency, and other metabolic processes would more likely affect the dorsal columns than the central cord as seen here, and while syphilis and HIV are possible, he notes he has recently tested negative for these.

What is your avg daily pain level?
Does it increase with any activities?
What kind of work or activities do you do?

I see the mention of a past head/neck injury, did you ever have any (very good) phys therapy or chiropractic treatment for that ?
Past injuries can show up later in life as we age.

Head impact/whiplash can cause misalignment at the C1/ C2 also called atlas /axis.
Up C Spine - A New Approach - Sign / Symptom Checklist

My average daily pain is actually pretty good right now, about a 1-2. I started Diclofenac about 2 months ago and it's been an absolute game changer for my pain. Before that, I was about a 5-6 every day.

The pain definitely increased with activities; to the point that I was pretty sedentary. It seemed like everything made it worse. Now that it's so much better, I've started doing things again like walking and PT.

I'm a software engineer so I spend a lot of time at the desk. I've invested in an ergonomic setup and for the most part, the job doesn't cause me pain. Activity wise, I really refrain from any sports. I've started walking a mile a day because I was recently diagnosed with osteopenia and I need to get some weight bearing activity. I start to get sore at the neck at the mile mark but it's tolerable.

I've done PT several times at several places over the years. I've currently doing it and think I found a good one finally. The past few providers I saw made my pain significantly worse. This new one is really taking it slow (crawling, rolling, etc..) to build me back up and I like that. I'm not sure how I feel about a chiropractor. I'm very anxious when it comes to my neck because of the myelomalacia.

I've really been trying to keep pain out of my decision on whether or not to have surgery now. I know I can't be on the Diclofenac forever as it can cause kidney issues as well as other risks but my pain is currently managed well. What keeps me up at night is if I'm doing damage to my spinal cord by not having surgery and the possible consequences of not acting now. That make sense?

OP: There are many failed surgeries and remember once done, can't be reversed. I've lived with spine problems and I'm 83 and hear of those who have done a lot of surgeries and in a lot of misery.

Look at PRP therapy and I've posted a lot about it here. PRP providers are all over the U.S. and the world.

Find Regenerative Medicine Doctors - GetProlo.com

Seek out a provider who has been doing this work for some yrs.

OP: Here is a link on cervical issues and PRP. I have neck issues that is arthritic and I've learned to live with it. Taking Inositol I find helps to "relax" my neck more.

Ultrasound-Guided Cervical Intradiscal Injection with Platelet-Rich Plasma with Fluoroscopic Validation for the Treatment of Cervical Discogenic Pain: A Case Presentation and Technical Illustration

Welcome, DesiBear--

Studies have been done showing that spinal fusion surgery is often unnecessary. I myself have questions about any spinal surgery although there are surely times when it is essential and improves a person's life.

I've known too many people who have had spinal surgery and come out with worse problems than before.

Any surgery is a trauma. If you can possibly avoid subjecting yourself to an invasive procedure that will be traumatic for you, by all means skip the suggested surgery.

A good question to ask a doctor who suggests surgery is: "What will happen if I don't have this surgery?"

Since you mention that 3 surgeons have advised not having surgery, why not go with that advice? It sounds as if you're managing to get along in spite of the symptoms.

Your children are young only once, and why not enjoy their childhood and wait and see? Myelomalacia can be quite serious but if 3 surgeons advise against surgery, and you surely don't want to put yourself through that whole experience if you don't have to, I'd say there's a lot to be said for watchful waiting.

Hi Desi
 

You have a long history with your neck. I Would urge you to contact a surgeon that has experience in Artificial Disc Replacement (ADR) or Total Disc Replacement (TDR) before going with any fusion. I had fusion surgery and it lead to yet another surgery. At least see if you are a candidate. My first recommendation is Dr. Ali Mesiwala in California or Texas Back Institute.

Thank you all for the replies. There seems to be a lot of caution against having surgery, which I totally understand and appreciate. I've asked my surgeons what happens if I don't have surgery now. The ones who aren't recommending surgery now say that I will likely develop more neurological symptoms as my cervical structure degenerates as part of the normal aging process and I have will show symptoms of myelopathy. They seem to think that if caught early when I develop those symptoms, they can be reversed. The surgeons recommending surgery say that if I don't have surgery in the near future (~ 6 months) that I will also develop worsening neurological symptoms and they may not be reversible because it may be due to increased myelomalacia. They also add that if I don't have surgery soon and am in some sort of traumatic event, my likely hood of paralysis is greatly increased. This is where my dilemma is, who do I trust with these conflicting opinions? I think going with the masses makes sense, I just wanted to get 1 more opinion before making a final decision.

As far as types of surgery, I'd definitely be looking for disc replacement and have seen a few surgeons that perform those procedures. The most recent surgeon I consulted with was fresh out of school and said that in a few years from now, that'll be the norm instead of fusions. I've been told by a few surgeons that because I have so many levels with issues, I'm not a good candidate for disc replacement, though others have said they would do 2 levels or a hybrid of fusion and replacement. Again, conflicting opinions...

I'll post back after I have my final consult at the end of the month. So far I've seen only orthopedic surgeons. My last appointment is with a neurosurgeon. I'm curious to see his take on it.

Thanks again to all who have replied. I'll definitely look into some of the recommendations.

So I saw my 6th surgeon and there's an even split of surgery/no surgery recommendations. I'm going forward with it though, specifically a laminoplasty. The 2 surgeons that recommended this are both professors at good universities. Their rationale is preserving motion while protecting the spinal cord. I did a little research and it seems that I have a risk factors for an increased risk of c5 palsy given my cord signal changes at c4-c5. I'll have to get more info on that before going forward. I'm targeting January, after the holidays. It's scary stuff but so is continuing on without doing anything. This seems like the best decision I can make for my situation.

I finally went through with the surgery on 04-28-22. Spent 5 days in the hospital but recovering well so far. Have my first follow up visit on 05-10 so we'll see how successful everything went. I plan on doing a write up after a few more weeks and after additional imaging.

Attached is an image of the entry site. I was told the incision was only supposed to be 3 inches but it appears much larger.