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.
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