We would like to take this opportunity to welcome Tim Boerger to the myelopathy.org team,he will be contributing to the blog by writing summaries of recently published research.
Tim Boerger is a Ph.D. student in rehabilitation science at Marquette University in the United States. His dissertation research focusses on walking and balance function in patients with cervical myelopathy. He himself had an Anterior Cervical Discectomy and Fusion in November 2016 for a cervical disc herniation with myelopathy. Prior to all of this, he worked for several years providing rehabilitation for patients with leg, shoulder, back, and neck injuries.
Tim's Story Pre-Op
A little about myself, I am currently 29 years old living in Milwaukee, Wisconsin, United States of America and for work am a graduate research assistant and PhD student at Marquette University. What led up to me being diagnosed with myelopathy occurred a couple years ago back in summer of 2016. My wife and I had just purchased a house and the best I can figure, I hurt my neck while we were moving.
Fast forward about 2 weeks (to early August) and I started to develop mild to moderate shoulder and neck pain along with some nasty "knots" in my heck and shoulder. Since I couldn't think there was any immediate injury, I assumed this was due to sleeping wrong or improper ergonomics at my workstation. This was persisting for about 6 weeks to late September, and I was managing the pain with some Aleve.
Now it's late September and I woke up one Saturday around 4:30a.m. with the worst physical pain I have ever experience. It quite honestly felt like every muscle in my entire left shoulder, arm, and forearm was spasming and cramping simultaneously with a sharp, aching, and burning pain in my shoulder radiating down my arm. This would spike any time I tried to move it. Eventually that day, I started to also feel numbness and tingling develop in my left thumb and index finger. At this point, I SHOULD have known what was going on. I'm an athletic trainer (which in the U.S. is a profession that specializes in injuries and illnesses related to physical activity and athletics) and a PhD student in rehabilitation science. I've taken 8 graduate credits of neuroanatomy and neurophysiology. I should have seen it, but I was blinded by my own stubborn pride. "I am too young for something like that to happen without a serious injury" and "I have no mechanism of injury" were my thoughts. "It must just by a tight muscle pinching a nerve root from all these knots" was my conclusion.
I. Should. Have. Known.
I ended up going to a local walk-in clinic the next morning and, sure enough, the diagnosis was herniated disc. They prescribed me some weak pain relievers and said they didn't expect them to work and that I may just end up in the E.D. that night asking for something more serious. So, we went over to the E.D. right away. They gave me a prescription for Percocet and got me an MRI of my cervical spine. The MRI results came back not good. *WARNING medical jargon*: I had an extruded C5-6 disc herniation with severe foraminal stenosis (narrowing of the hole for the nerve root to go out to the body), mild-moderate cervical canal stenosis (narrowing of the hole for the spinal cord), and mild spinal cord deformity. I was scheduled a follow up appointment with a neurosurgeon a couple weeks later. I, however, wanted to try and get seen a little sooner and start on some conservative treatments so I managed an appointment with a Physiatrist in the mean time. Her impression was that the injury was not that significant and, in particular, the spinal cord deformity wasn't too serious since I had plenty of room for the spinal cord still. I got started on physical therapy. About a week after that, I had a couple physical therapy sessions in and saw the neurosurgeon. Up to that point, PT wasn't really helping the pain that much, and the pain was too bad to be able to do any exercises. At the surgery visit, the surgeon was less optimistic. She found something that wasn't present before, known as hyperreflexia, in my left hand. This meant that the the compression on the spinal cord was an issue after all, and she was pretty confident I would not be able to recover without surgery.
What is hyperreflexia: (*WARNING more science-y stuff*: basically the brain sends inhibitory signals down to the motor neurons in the spinal cord to prevent reflexes like the knee tap reflex from being too strong. If the nerve sending that descending signal is compressed, the signal doesn't get through and the reflex is stronger than it should be…. i.e. because of the compression, there is less information from the brain getting through to the motor nerves in the spinal cord to tell them to be quiet.)
The surgeon was willing to continue trying conservative therapy on the condition that if I didn't notice improvement within 6 weeks to 3 months, I should go ahead and schedule surgery. I tried a couple more weeks of physical therapy. This ultimately didn't help at all and may have made me feel worse in the short term. In this time, I had a medical genetics test, that I basically bombed due to pain, and tried my best to struggle through classes and work in spite of the pain. After about 2 weeks, I had a follow up with the Physiatrist I had seen. She confirmed the hyperreflexia the surgeon had observed. We had a good discussion about the implications of that, and discussed that she also now believed I needed surgery.
By this point, I had already failed physical therapy (in the sense of it became evident that PT wouldn't help) and started on the path to schedule surgery. At work, my boss/advisor (since that is the same thing in a lot of PhD programs) and I discussed the implication on classes and work. I ended up needing to drop out of classes for the semester and ended up having to retake the next couple semesters.
Symptom wise, I also started to develop tingling in my right hand in my thumb and pinky fingers, which would indicate greater seriousness of the compression on the cord. About a week after that, I noticed tingling in my right foot and leg. A few days after that, I noticed that my walking was being impacted. Specifically, I couldn't lift my foot enough (dorsiflex) to clear my toe off the ground when I swung-through. This caused me to almost trip and fall a couple times. Therefore, I asked my advisor (a physical therapist as well) to check the strength of my right ankle. Sure enough it was a little weak compared to the left ankle. This was a week before my surgery was scheduled.
I ended up having surgery on Nov 15, 2016. The surgery went well though the overnight stay in the hospital was a bit rough. I was in quite a bit of pain, they wouldn’t let me have anything by mouth all night because I vomited after drinking shortly after surgery, and I needed a urinary catheter a few times. I was able to pass my inpatient physical and occupational therapy testing right away and went home the day after my surgery.
The surgical procedure is referred to as an Anterior Cervical Discectomy and Fusion. Briefly, that involves entering through the front of the neck to access the spine from the front. This has better outcomes because they can basically slide between layers of muscles rather than cut through them, like they would have to do from the back. In my case they then took out part of the disc, put in a cadaver bone spacer between the vertebrae, and put a titanium plate over the whole deal. While before surgery, they didn’t think I really had a case of myelopathy, due to the onset of symptoms in the other hand, foot, and walking problems the operative diagnosis was a herniated cervical disc with myelopathy.
After surgery, I continued to be in pain from the surgery for several weeks. I had some problems swallowing for about a week or two, and sleep was uncomfortable at times for awhile
I returned to work on January 5th with restrictions. Basically, I could only do computer work for awhile until the two vertebrae fused. I was on a 10lb and then 20lb weight restriction since surgery. At my 3 month follow up appointment I had a couple of x-rays taken in maximal extension and flexion to see how the fusion was progressing. everything is going well on that part. because that was going well, I was cleared to return to work without restrictions. After this point, I spent a lot of time working on re-strengthening my arm and working on my balance. Also by this point my pain levels were much better, and I was able to return to classes for the Spring semester of 2017 which began in January.
At the 6 month follow up I was continuing to do better, having less and less pain and increased strength. Likewise, at the 12 month post op follow up in November 2017 things were going quite well and I was discharged from the care of the neurosurgeon for this surgery. I still have some pain intermittently at 1.5 years out from surgery, especially if I neglect my posture which I manage with over the counter Tylenol or Aleve. All-in-all, I am doing very well all things considered.
by Max Stewart
It appears that the story isn’t quite as simple as we might initially think. Could there be other factors, beyond gross compression of the cord, which determine whether or not someone develops myelopathy?
A group of researchers at Wenzhou Medical University in China, led by Wu Shiyang , thought that one such factor could be reduced spinal blood flow. They reasoned that the same degenerative changes that compress the spinal cord in older people could also compress the blood vessels that supply it, the so called ‘spinal arteries’ (Figure 1). If these arteries became compressed there would be less oxygen reaching the cord, leading to death of nerve cells and inflammation of the surrounding areas. This damage to the spinal cord could lead to the symptoms of myelopathy.
What did this study involve?
To test whether spinal artery compression is associated with myelopathy, the Chinese researchers decided to look at the blood flow in one of the biggest arteries supplying the spinal cord, the anterior spinal artery (Figure 2). They compared flow in this artery between healthy people and people with DCM. The researches also compared blood flow before and after CSM surgery, to see if there was any link between improvement in symptoms and restoration of blood flow to the cord.
To look at blood flow, the researchers used an advanced technique called ‘dual energy computed tomography’ (DECT). Normal CT scans are used widely in hospitals, and some groups have tried to use them image blood flow in DCM. However, these efforts have been unsuccessful . Shiyang’s group are the first to use the more advanced DECT instead, which is able to produce better pictures of blood movement within arteries. DECT is complicated, but here’s a (very) simplified explanation. First, Iodine is injected into one of the patient’s arteries. The patient is then placed in the CT scanner. Two sets of mages are produced; one using a high energy X-ray beam, one using a low energy beam. Body tissues look similar in both types of X-ray, but iodine looks very different. By combining the two sets of images, a computer is able to focus on body structures that contain iodine – in this case, the arteries. The computer can then see how much iodine is flowing through the arteries and use this to work out blood flow.
The study involved 50 patients with confirmed DCM and 10 health patients. Both groups underwent DECT scans. The DCM group had their level of disability measured using the JOA score. The DCM patients then had surgery – each underwent an anterior cervical discectomy and fusion. The DCM patients then had another DECT scan after surgery (to see if blood flow in the arteries had changed) and then had JOA scores calculated again one month and six months after surgery.
Researchers then looked at:
1. The difference in blood flow between pre-surgery DCM patients and healthy patients
2. The difference in blood flow between pre-surgery and post-surgery DCM patients
3. Any link between change in JOA score (disability) and change in blood flow after surgery
What did this study show?
There were three important results from this study:
1. Blood flow through the anterior spinal artery is significantly lower in pre-surgery DCM patients than healthy patients
2. Surgery leads to a significant increase in spinal artery blood flow in DCM patients
3. Patients who had bigger improvements in blood flow after surgery had greater recovery in JOA score (i.e. were less disabled) 6 months later
What might these results mean for the future?
This study suggests that reduced blood flow to the spinal cord could be associated with the symptoms of myelopathy and that improvement in blood flow could help predict to recovery from surgery. These links between spinal artery compression and myelopathy could be important because:
1. They could help us better understand the underlying processes which damage the spinal cord in DCM, which in turn would help us develop new treatments. These results could even help explain why spinal cord compression on imaging doesn't always cause DCM – perhaps compression of the spinal arteries is also required for symptoms to develop.
2. They could help us diagnose myelopathy earlier. Reduced spinal blood flow could now be considered a sign of DCM, which we can combine with our existing diagnostic makers (MRI scans, neck pain, disability etc). The earlier we diagnose myelopathy the sooner we can operate and the less severe lasting disability will be. Remember: time is spine.
3. They could help us assesses how successful surgery has been and predict how much recovery we can expect. A big improvement in blood flow suggests that recovery will be better. This clarity can help us plan your future care and helps you know what to expect.
4. They could help us compare treatments to see which is best. Surgeries that produce the bigger increases in blood flow may lead to better recovery than surgeries which produce smaller improvements in blood flow. Shiyang’s group has already planned studies to see if DECT can be used to compare outcomes of anterior vs posterior decompression operations.
What are the limitations of this study?
Obviously, use of DECT and study of blood flow in general is still at a very early stage. Most hospitals don’t have access to DECT yet, so it will be a while before we could think about using it in diagnosing DCM. We’d also need to confirm that there is a consistent difference between healthy and DCM patients that is big enough to detect. Furthermore, we don’t know what processes reduced blood flow is actually triggering to the spinal cord. Finally, it is likely that compression of arteries is only one of many changes and disease processes that drive DCM. Time will tell just how significant the contribution of reduced blood flow is to the disease.
1. Shiyang, W. et al. Is Cervical Anterior Spinal Artery compromised in Cervical spondylotic myelopathy patients? – dual energy Computed tomography analysis of Cervical Anterior Spinal Artery. World Neurosurg. (2018). doi:10.1016/j.wneu.2018.03.217
2. Zhang, Z. & Wang, H. CT angiography of anterior spinal artery in cervical spondylotic myelopathy. Eur. Spine J. 22, 2515–9 (2013).
Here are a few helpful things to get you started.
Firstly you need to go the Social Security Administration page. You can apply online, or have the forms sent to your home.
Social Security Benefits (SSI)
As far as Social Security benefits, SSI is a set disability amount which is awarded for those who have not worked enough years or haven't paid enough social security tax into the system. For example, the maximum amount right now is $750/monthly. SSDI benefits are disability benefits awarded based on wages over the years and paid into Social Security. You could range anywhere from a couple hundred to a couple thousand dollars monthly. Both benefits are issued through the social security administration.
You need to be deemed disabled for an expected period of at least 12 months. For disability, benefits, especially SSI, most applicants are denied the first time. That's typically when one obtains a lawyer to handle the appeal. It just seems to be common practice. It can take months to finally get approved. Obviously depending on the level of severity, but it can take anywhere from 6 months to a little over a year.
As far as medical coverage, there are programs through public welfare and types or medical coverage available associated specifically with disability. One is directly related to SSI recipients, one is disability clients with no income/awaiting benefits, there is one for those who work but fall under certain income limits, one for those receiving SSDI who fall under certain income limits, and for those who receive SSDI and receive Medicare part B through social security - if they make too much to qualify for the welfare medicare, there's another income limit to see if welfare will at least pay their Medicare B monthly premium amount, so they would at least have that premium amount back in their pockets in the SSDI check. All of those types of medical are applied for through Dept. Of Human Services /formerly Dept. Of Public welfare.
If anyone in the US is looking for cash assistance while awaiting disability, they can also apply through Dept Human Services. For example, the guidelines to qualify for cash assistance benefits is that you have to have care/control of a minor child. So a parent/parents with custody. The amounts are very low though, right now, if a parent of 2 applies for cash assistance, and has zero income, the maximum grant amount monthly for that 3 person household is only $403. Better than nothing but clearly doesn't touch the bills. There are job search requirements with this program. But if you are disabled, you have a form completed by your physician and are waived from those requirements. We also have what is called a DAP- Disability Advocate Program, and they can help individuals seeking SSI throughout the process.
Each state has different programs to help the disabled offset costs.
Some states have fuel assistance. Every year , a household gets a certain amount of money paid to their heat supplier for heating through the winter.
Most disabled people , if qualified can get SNAP, which is the food stamp program.
If you've got young children under the age of 5 , there is the WIC program which delivers food to low income mothers.
If you are disabled, and get SSDI, your children get a small disability check also. That lasts until they are 18, or have graduated from high school.
Most states have food banks, if you need food please use them.
Churches also have programs for food, the elderly, and the disabled. Ask your pastor for any information or programs that could help your family.
Disability Benefit Centre
Information kindly collated and presented by Margot Miller and Melissa Rodriguez
If you have any relevant information on the benefit system for the USA and would like to see it featured please get in touch: firstname.lastname@example.org
All this information is now available at www.myelopathy.org/disability-benefit-advice-usa.html
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