Advice on neck (cervical) pain/surgery

Kim · 03-03-2005, 14:10

Hi, I am a new member...Bill Harsy said this is a good place to ask questions and get great feedback. Thanks in advance for your help and time...its much appeciated.

I had an MRI 10/5/04 which said in part: At C5-6, there is a moderate to marked broad-based protrusion of the intervertebral disc with hypertrophic changes along the body margins and uncovertebral joints particularly on the right. There is severe compression of the anterior spinal cord. Marked narrowing of the right neual foramen is noted.

At C6-7, there is a moderate broad-based protrusion of the intervertebral disc with hypertrophic changes along the body margins as well as the uncovertebral joints particularly on teh right. There is a moderately severe compression of the anterior spinal cord as well as marked narrowing of the right neural foramen.

There is some linear increased signal intensity of the anterior spinal cord adjacent to C5-6-7 which may suggest cord edema or myelomalacia. High signal intensity at the adjacent end-plates of C6-7 represent degenerative changes.

There is a loss of signal intensity throughout the cervical intervertebral discs.

On good days the pain is central (base of the neck). Bad days it radiates down the right scapula, down my right arm/hand. Sometimes it radiates up the neck and around the jaw/head.

I have gone through the conservative treatments...pt and 2 cervical injections, one in C5-6 and the other in C6-7. I was scheduled for a level 2 Anterior Cervical Discetomy and Fusion...then decided to get a second, and maybe third opinion.

What are some good questions to ask during my consultation? What are the top neurosurgical medical universities these specialists are trained? Portland OR is a relatively small city...there are only a handful of neurosurgens. The first neuro I went to, was not interested in taking the time to answer my questions.

Stargazer · 03-03-2005, 15:15

Hi Kim, Welcome to the board. Sorry to learn about your current condition. When I research experts and cutting edge technology... I follow the money. NIH/HHMI grants to Medical Schools are always a good start.

In the limited time vested, I have found this source. Hope it proves of some interest.

http://www.ninds.nih.gov/funding/are...y/fore_sci.htm
http://www.usnews.com/usnews/health/...pecihqneur.htm

Best of luck to you!

~ edited to add 'usnews' link

**Eagle5US** · 03-04-2005, 22:33

Hi Kim,

So sorry to hear of your current state...though I will not elaborate on the possibilites your diagnosis may imply...try and keep a few things in mind.

-ANYTHING dealing with that licorice string protected by your vertabrea is important ,and significant, no matter how small a doubt or question.

-As health care providers, YOU are our EMPLOYER. You have every right to ask the questions and expect to be given the answers and time it takes to have them explained to your satisfaction.

-Any provider who doesn't or won't answer your questions is either lazy, or deosn't know (and doesn't want to take the time to find out)...you want NEITHER of these folks as your provider.

Keep at it...ultimately, you will be the one to live with your decisions for care, and the results of those decisions.

Eagle

Kim · 03-07-2005, 09:51

Thank you Eagle...it was a tough decision to back out of surgery and decide to find another neuro, who is willing to take the time to answer my questions. Your response made my day. Kim

Kim · 03-07-2005, 12:13

Stargazer, I just finshed checking the sites you listed...very informative. Thank you for taking the time to put the info together, I now have pages of good stuff printed. You are right...follow the money. Kim

Sacamuelas · 03-08-2005, 16:54

Kim-
I am coming at this from the angle as an educated patient, not as a member of your healthcare team. It is VERY important for you to understand the context this is written in as well as its intended purpose. No one on the internet could or should try to diagnose/recommend treatment of conditions as potentially serious as your current ailment. With that in mind, please understand that only you and your team of healthcare providers can properly evaluate your ability to be a good candidate for this type surgery. Another important point to address in your consults is to verbalize exactly what “clinical success” of the surgery means to you, and the actual surgeon’s idea of acceptable clinical success.

One thing I have found is that it is very difficult to ask good questions unless you know a little about the topic. Therefore, to help you out I thought I would give a little basic information. This information below needs to be used only as a guide for you to ask questions. The answers from your Doc based on your specific situation can then be used to ask more pointed and detailed questions. As has been posted already, those Doctors work for you. This doesn’t mean you are precluded from showing the proper respect for them due to their education/experience/expertise. It means that you should expect honest and complete answers to your questions and have a right to be informed of your current medical situation. I have always found, the more knowledge a patient has- the more specific an answer can be provided due to their already existing background knowledge. Therefore, this is the intention of these posts - to give you a little background knowledge. Forgive me if you already knew/researched all of this.

First, you need to grasp the basics and terminology. When you read the MRI report you have, do you understand what it says? Do you know what each word means in the context of this situation? If not, then we should go over what isn’t clear to you.
Here are two VERY basic multimedia presentations designed for patient education. I thought they might give you an introductory understanding.

http://www.drdillin.com/education/an...n_cervdisc.htm

http://www.drdillin.com/education/an...niateddisc.htm

As far as questions I would ask- There are lots of them. I would break things down into sections and write them down. FWIW, most surgeons will recommend specific procedures and not give much choice to the patient on the specifics of the surgery. However, there are a few things in these type surgeries that are "clinician preference" type choices based on that particular surgeons experiences, training,etc. These are the things that I would really focus in on in my questions when comparing different surgeons during your consults. For example:

On the particular aspect of the fusion of the cervical vertebrae.. I would ask specifically what type of grafting is to be done. I would also ask whether any instrumentation was to be performed (ex. Plating with screws to fix the vertebrae together after the graft is placed). Here is a little background info to help you decide which option might be preferable to you.
For the type procedure that was recommended to you, there are two commonly used types of grafts.
Autografts (ex. harvested bone from the inner aspect of your iliac crest) or allografts (human bone harvested from cadavers, etc and then prepared for use later) are the two main types.

Autograft:
There are three main types of Autografts that can be harvested.
1. Autogenous cancellous bone represents the most effective graft material for achieving spinal fusion. It possesses all 3 necessary graft properties: osteogenic potential by transplanting bone and marrow cells, an osteoconductive matrix, and osteoinductive matrix bound proteins. Cancellous bone also has a large trabecular surface area for new bone formation.
2. Autogenous cortical bone offers the advantage of greater mechanical strength, which may be desirable in situations such as anterior cervical fusion. Cortical bone, however, has fewer osteogenic cells, less surface area for new bone formation, and is more resistant to vascular ingrowth and remodeling compared with cancellous bone.
3. ***Combined corticocancellous grafts from the iliac crests are commonly used. This type of graft contains a mix of the best properties of both types above. Note: The mechanical strength of anterior iliac crest grafts has been reported to be greater than that of posterior grafts.
The major disadvantage of autogenous grafting is related to the morbidity associated with graft harvesting such as donor site pain, increased operative time, cost, blood loss, and potential for infection. In addition, the limited supply of graft material available may be insufficient for long multisegmental fusions. Vascularized autografts may be useful to span large defects and in areas of radiation induced fibrosis or previous infection. Autogenous bone marrow is also a valuable source of osteogenic cells commonly used by surgeons as an adjuvant to allograft bone grafts.
Allograft:
Allograft bone is an attractive alternative to autograft bone for many reasons. Allograft bone negates donor site morbidity, comes in a wide variety of shapes and sizes, and is a potentially unlimited source of grafting material. In addition, cortical allografts provide the surgeon access to grafts whose mechanical strength is superior to autograft.
Autograft bone is nonetheless the gold standard of comparison for bone grafting and the preferred choice for graft material in almost all circumstances. It has a higher healing rate compared with allograft bone and carries no risk of disease transmission.
The risk of disease associated with allograft bone is actually quite low. Including the risk of receiving a graft from an HIV-positive donor, the risk of disease transmission due to allograft bone is estimated to be well over 1 in 1 million.

(continued below due to size)

I have been extraordinarily busy at work this week and keep getting interrupted trying to type this up... was this what you are looking for Kim? Just trying to help the Blademaster's friend out.

Sacamuelas · 03-09-2005, 09:05

Note-
Kim, I have personally performed surgeries using both types of surgical grafting techniques I discussed above. For the autograft, we harvested a portion of iliac crest for use as a graft. We used it to reconstruct a semi trucker's upper jaw (maxilla). He had an unfortunate chance encounter with a heavy duty metal connector attached to a tie down strap under extreme tension as he was tightening down a load when it gave way. I also use allograft materials monthly for small defects.

Besides necessitating a second surgical site, an important issue to be aware of is the discomfort after the surgery on the donor site. A lot of patients find their hip to be more sensitive and painful than the actual graft site. Some of this can be mitigated by discussing with your surgeon where (anterior vs posterior) on the iliac crest the graft will be taken. Its worth discussing if you decide on an autograft.

The autograft is definitely the best material we have since it has all three properties (osteogenic (can make bone itself with its cells), osteoconductive(works as a matrix for new bone to "grow into" it), and osteoinductive( has cells that initiate the bone around the graft to begin "growing new bone" into the graft tissue).

Just thought I would add that little tidbit of information so you didn't think you were getting a purely internet based opinion. In my profession, we do a little bone grafting too... just not on the spine.

Sacamuelas · 03-09-2005, 09:27

On another note-
I don't completely agree with one of the other poster's advice above. It's not "wrong", its just not what I would do.

I don't choose my doctors and surgeons based on the ability to write grants. The grant process itself has a fairly strong political and social component to it. Another component is how well the writer can put things into written form that the bureaucrats and administrators making the decisions can understand. I am not saying that a doctor or hospital that receives a lot of grants is not outstanding... it just isn't a factor that I use when deciding treatment for myself or my family.

Get out there and talk with any MD friends of yours. Ask around... get the Docs you know to ask around. There are almost always very good choices regionally, but it takes asking about personal experiences, results from past referrals, and about inter-colleague professional reputations to really find out the truth. Ask the docs you talk with who THEY would take their daughter or son to get this surgery performed.

Stargazer · 03-09-2005, 09:56

Sacamuelas, I could not agree with you more about not choosing a doctor based on grants writing and monies.

It was offered as a starting point for finding institutes that are well funded and top-ranked in a given specialty. Top institutes attract talent as the best tend to gravitate towards resources that will best support their mission.

Kim · 03-10-2005, 14:08

Quote:

Originally Posted by Sacamuelas

On another note-
I don't completely agree with one of the other poster's advice above. It's not "wrong", its just not what I would do.

I don't choose my doctors and surgeons based on the ability to write grants. The grant process itself has a fairly strong political and social component to it. Another component is how well the writer can put things into written form that the bureaucrats and administrators making the decisions can understand. I am not saying that a doctor or hospital that receives a lot of grants is not outstanding... it just isn't a factor that I use when deciding treatment for myself or my family.

Get out there and talk with any MD friends of yours. Ask around... get the Docs you know to ask around. There are almost always very good choices regionally, but it takes asking about personal experiences, results from past referrals, and about inter-colleague professional reputations to really find out the truth. Ask the docs you talk with who THEY would take their daughter or son to get this surgery performed.

Thank you Sacamuelas, for your time and expertise. it's much appreciated. I actually went into my meeting with my neuro with 2 pages of questions...because as you said and I completely agree, its best if patients are informed. I did my research (my pt is a great source of ed, though I'm far from knowing all thats involved (Thank you by the way for the multimedia presentation). I am and always will be an active participant in my health care. A couple questions I asked:

1. Why didn't the cervical injections/pt work for me? His answer- they work 50-60% of the time, why it didn't work for you...I don't know. I asked this because my pt said it had to do with compression on the nerve root.

2. Is my condition something that could ever get better with physical therapy and cervical injections if I continued this course? His answer-I don't know. I was hoping for some reference to the degeneration, stenosis and compression...just something. I don't expect him to predict the future, but I do want him to give me some indication of the possibilities in store given my condition. Could it progressively get worse? Nerve damage?

3. How will the stenosis be treated? His answer- thats the least of your problems. I asked this because my pt explained that excess bone would be cut away. I wanted to know if that was the case and what to expect in surgery.

Did I ask unanswerable questions? Should I rephrase them? Were they too vague/subjective/silly? I felt as though my questions were... dismissed.

I did find out the grafting would be done by bone from the bone bank (allografts), and that a metal plate with screws would be used.

My next appointment, with another neuro is 3/22. And I have asked (through the grapevine) about him...and have received very good responses about his rep. I will PM you concerning some specific medical terms I am unfamiliar with. Your explainations are very exact and understandable, a very commendable trait. Kim

**Bill Harsey** · 03-11-2005, 20:11

To you all who have answered Kim,
Thanks from me.

Kim, I hope this isn't from something we did while water skiing behind a drag boat on the North Fork Resevoir out of Estacada Oregon.

Or jumping into your pool (late at night) in January. It wasn't that big a deal except for that layer of pesky ice on top.

Thanks again Crew, Bill

ccrn · 03-12-2005, 10:28

To me..."I dont know, I dont know, and I dont know" is dismissing your questions.

It is my experience that the best Doctors dont necessarily have the best bed side manner, but they should be able to give you concise answers to your questions.

Your PT seems to have been a good source of info for you. Can he/she recommend a good surgeon in your state or region?