Left cervicobrachialgia following cervical discectomy
43-year-old male suffered of cervical disc herniation, and therefore C5-6 and C6-7 discectomy and fusion were done. About one year later he experienced acute sciatica followed by hot pricking sensation in the arm and neck. MRI showed far lateral bulge of L3-4 on the left and small disc bulge on C4-5, and a larger C5-6 disc herniation. Neurological examination disclosed C6-C7 radiculopathy on the left, minimal weakness of biceps and triceps muscles and reduced biceps reflex. EMG and physical examination were consistent with bilateral radiculopathy, attributed to small disc herniation. The type of pain is reported as "neuropathic".
1. What do you think might be causing this clinical picture – recurrence of herniated disc or cicatricial fibrosis?
2. If you think it might be the recurrence, do you feel it may be the result of the surgical procedure carried out in September 2006?
3. Despite the various benefits obtained from the postural exercise, why is there still to date a constant and persistent burning pain in the left leg? In addition to the lumbar MRI, which was negative, is there any other useful test to try and establish a diagnosis?
4. Can you suggest any other therapies?
Sex: M, Age: 43 years
Diagnosis: Left cervicobrachialgia following cervical discectomy.
- Left leg distal lacerocontusion wound III at 6 years of age
- Tonsillectomy at 14 years of age
- Appendectomy at 22 years of age
- Mononucleosis in 1995
- Syphilis in 2004, treated for approximately 2 months
- In 2001, the patient reports a full spinal contusion trauma as a result of an accidental fall
- In 2001, hepatic colic with an ultrasound diagnosis of “dysmorphic gallbladder”.
Recurrent and progressively more severe cervicalgia for many years, affecting the arms and subsequently the legs. Initially treated with medical and physical therapy.
In March 2006, burning, localized pain in right parascapular region and paresthesia in first 3 fingers of right hand.
An MRI was performed in August 2006 with a diagnosis of a C5-C6 disc protrusion; C6-C7 bulging disc hernia located in the right median/paramedian region.
Therefore, in September 2006, the patient underwent a microdiscectomy neurosurgical procedure at C5-C6 and C6-C7 using Caspar’s technique:A voluminous right medio-lateral hernia was removed at C6-C7; the presence of an arthrotic disc compression at C5-C6 was removed exposing the dural plane.Number 5 carbon cage at C6-C7 and number 4 at C5-C6.
During the Christmas period in 2007, sudden onset of severe sciatica, followed subsequently by onset of a hot pricking sensation in the left arm and left half of neck.
Therefore an MRI was performed (Jan. 2008):
- Cervical vertebral column:
Reduction in physiological lordosis as far as could be observed in clinostatism. Diffuse spondyloarthrotic signs with abnormalities in somatic limits. Marginal osteophyte formations. Dishomogeneous reduction in size of all intersomatic spaces, in which the discs appear hypointense in the TR-long sequences due to dehydration phenomena.In the intersomatic space between C5-C6 anteriorly within the vertebral canal in the right median/paramedian region there is an isointense formation on the disc pressing on the dural sac and reducing the size of the homologous lateral recess attributable to a small disc hernia. No expansive processes in the endospinal region.Size of vertebral canal within normal limits.Normal appearance and signal response of examined medullary chord, cone and caudal roots.
- Lumbosacral column:
Reduced physiological lumbar lordosis. No morphology or focal-, evolutive-type signal abnormalities of examined vertebral bodies.
Normal appearance and signal response for examined intersomatic discs.No disc hernias or expansive processes in endospinal region. Size of vertebral canal within normal limits.Normal appearance and signal response of examined medullary chord, cone and caudal roots.
The patient had a neurology visit (Feb. 2008) the results of which were left cervicobrachialgia with C6-C7 radicular distribution; minimal strength deficit of left bicipital and tricipital muscles; Osteotendinous reflexes = weak left bicipital muscle. Therefore, the patient was advised to have a cycle of PKT (massage therapy, posture exercise, etc.) + pharmacological therapy with Bentelan (1 vial 1.5 mg a day for 5 days) and Lyrica (1 tablet 75 mg a day for 10 days).Lastly, the patient was advised to have electromyogram (EMG).
At a further neurosurgical specialist visit on Feb. 2008, the patient was advised to undergo a cycle of global postural motor re-education program and to have an EMG for a differential diagnosis of polymyositis.
EMG of Feb. 2008:
Arms: Signs of medium level stabilized chronic neurogenic abnormalities relating to right C5-C6 roots.No current denervation of examined muscles.The examined motorsensory conduction is within normal limits.
Legs: No significant abnormality of motorsensory conduction, delayed muscle response and electrical activity recorded in examined muscles.The test is within normal limits.
At the same visit, a neurology examination was performed with a detailed description of the clinical picture:“bilateral lateral cervicalgia, primarily on the left, involving spinal pain and abnormalities of the median and ulnar nerves due to C5-C6 radiculopathy secondary to a small disc hernia pressing on the dural sac within the vertebral canal, reducing the size of the homolateral recess.This small hernia is located at the level of a disc (C5-C6) that was partially excised, together with disc C6-C7 as a result of a previous herniated disc at C6-C7, in September 2006. Clinically, the patient experiences neuropathic pain both in the left lateral cervicobrachial region and in the tributary areas to roots L4-L5-S1 primarily on the left.Despite specific therapies, including both drugs and postural exercise, the patient’s professional activities are significantly reduced and hindered by the above symptoms.”
Due to the persistence of the above symptoms, the patient had a further MRI of his cervical spinal column on March 2008, the results of which were as follows:
“abolition of cervical lordosis as far as can be observed in clinostatism. Signs of surgical procedures at C5-C6, C6-C7.
In the intersomatic space between C5-C6 anteriorly within the vertebral canal in the right median/paramedian region there is a sign in the latero-ventral surface of the dural sac due mainly to surgical fibrotic effects with a concomitant minimal osteophyte formation.
Based on the tests and evaluations, the patient has not received a uniform response on the cause of his current symptoms. Some specialists interpret his condition as a recurrence in the C5-C6 region, as the disc was not removed in its totality, while other specialists feel the cause lies in cicatricial fibrosis at the site of the previous surgical procedure.
Currently, after two months of therapy, the patient has stopped taking the Lyrica and is taking allopurinol after lunch, having discovered that he has high levels of uric acid.
The type of pain is reported as "neuropathic", upper and lower extremity on the Lt. MRI that was carried out on the 3.08 showing status post C5-6, C6-7 discectomies and some compression on the Rt (disc?, fibrosis?). Anyhow, there are no findings explaining the symptoms that are on the left side.
In summary, the case presented to me is not clear yet. There is discrepancy in the clinical, radiological and electrophysiological investigation data. I don't see any indication for surgery, not in the cervical nor in the lumbar spine. The cause of pain is not clear: in the cervical spine the Lt radiological and neurophysiological findings are minimal if any and I don't believe that the findings on the right are responsible for the complaints. The findings in the lumbar spine are minimal and the small L3-4 far lateral bulge may produce some radicular symptoms of the L3 root on the left. If this is the case and no conservative treatment is beneficial, then coblation (minimal invasive nucleotomy) may be considered. The history of syphilis in the past was noted but there are no signs of late expressions of the disease.