Saturday, January 18, 2014

Unnecessary neck surgery

After 3 years of therapy my 60 year old patient feels well enough for a trial off antibiotics. During this recent visit I explored the topic:  when do you think you started having symptoms of Lyme disease?

She thinks it started 5 years ago with neck pain and a "pinched nerve."

Twenty percent of patients visiting their primary care physicians have chief complaints considered orthopedic.  One of the more common complaints is neck pain or shoulder pain.  Many of these patients also complain of symptoms which radiate into an arm. This is typically diagnosed as cervical radiculitis or cervical radiculopathy, also known as a pinched nerve in the neck. Large nerve branches called radicals, exit at intervals from the spinal cord between the cervical vertebral bodies. Vertebrae are numbered based on location. If a nerve root exists between the second and third vertebrae in the neck, called C2 and C3 the the corresponding nerve root would be C3. Almost all pinched nerves in the neck occur at the space between C5 and C6, causing C6 nerve root symptoms or between C6-7 leading to C7 nerve root problems. When these nerves are "pinched" symptoms referable to the sensory and motor functions of the particular nerve will typically be seen:  weakness, decreased sensation and loss of the relevant deep tendon reflexes. This is a diagnosis that any 3rd year medical student can easily make.

Doctors today rely more heavily on tests to make or confirm diagnoses. An MRI of the neck is typically ordered. A bulging or herniated disc or a bone spur will be seen in the corresponded area and the diagnosis is made. Simple. In some cases if more information is desired an EMG/NCV will be ordered.

Busy doctors frequently make a quick jump: neck pain to MRI. A diagnosis is made.

My patient with severe neck pain had been followed by her neurosurgeon for over a year.  The patient had been treated with a year of physical therapy and 3 epidural steroid injections all of which only intensified the pain. Her doctor said the finding on the MRI could not support surgical intervention and she should continue conservative measures.  On a subsequent follow-up visit her usual doctor was away and she saw a stand-in. He quickly proclaimed he could fix her pain with an operation. Desperate for relief she agreed to an operation. One surgery led to another. She's got the scars to prove it but her pain did not improve one iota.

Google cervical radiculitis or radiculopathy.  You will find the cause is a disc problem or a bone spur.  You will see that various therapies are available including surgical ones.

Lets go back to the test. MRI of the spine. Studies have been done in asymptomatic folks in the general population. At age 20 15% of folks have disc disease. By age 60 a striking 85-90% of asymptomatic individuals have disc disease in their neck according to MRI findings.

Lets go back to google. Now search Lyme radiculitis or radiculopathy and the connection will clearly appear.  If you had used the search word radiculo-neuropathy to start with Lyme would have immediately popped up.

These conditions looks like the same problem. With Lyme (and other infections) pain does not occur because the nerve is pinched but because the nerve is inflamed by the infection. In many cases there is a combination of the two. The nerve, a little pinched, asymptomatic, becomes very symptomatic when the nerve is inflamed by infection.

In the case of this particular patient she also had a "pinced nerve" in her back as well causing sciatica which worsened with a year of physical therapy and cortisone shots.

In her case both the neck and back pain completely went away with a course of antibiotics.

Radiculoneuropathy is a well known complication of Lyme disease described early on with Bell's Palsy and considered a form of neuroborreliosis in the literature.

An IDSA thinking neurologist recently published a paper which stated there are only three neurological manifestations of Lyme disease: meningitis, cranial neuritis like Bell's Palsy and radiculoneuritis.  His main point was discredit the notion that Lyme is associated with other neurological diseases like MS and ALS as frequently discussed by ILADS types.

My patient's warning:  Think twice before you undergo the knife for a pinched nerve in your neck. 

3 comments:

paulie said...

My opinion is that the vast majority of lumbar and cervical episodes are due to infection. I myself have had multiple orthopedic surgeries, including two total shoulder replacements, and two spinal surgeries. No neck surgeries, but several neck episodes causing marked weakness in one arm/hand. I know now it was all Lyme. I have been treating for 5 years and have not needed any orthopedic interventions during that time.

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Adriana henry said...

Humans make mistakes and that was the mistake by both of the physician and the patient as well but I am happy now that she is getting better at Physiotherapy North Ryde and will inform her friends and family as well to visit us first instead of the visiting any surgeon.