Hi,  My Question Is Only For Orthopedic And Neurologist Surgeons. 

Brief Answer:
Please let me know if you will accept my response before proceeding

Detailed Answer:
Good morning.

I have been noticing that your question has not captured responses over the past couple of days since you have restricted the candidates to only orthopods and Neurosurgeons.

In the interest of giving you what I believe is likely useful information as well as an answer to your question on the "condition of your nerves" I am reaching out to you to find out if you would accept my response as a NEUROLOGIST. I am not a surgeon, however, believe am sufficiently and duly qualified to answer your question specifically on the "condition" of your nerves.

However, since I do not want to impose by offering a response that may not be of interest to you I am writing this to message first to discover if you will accept my answers based on this fact of my being a NEUROLOGIST and not a surgeon.

In the event you prefer to await a neurosurgeon or another orthopod to answer I completely understand. Then, what you can do is CLOSE this query and request a refund from HEALTHCAREMAGIC at which point you may repost your question without any financial loss.

Many thanks for your attention. I await your response.

---

Brief Answer:
Please let me know if you will accept my response before proceeding

Detailed Answer:
Good morning.

I have been noticing that your question has not captured responses over the past couple of days since you have restricted the candidates to only orthopods and Neurosurgeons.

In the interest of giving you what I believe is likely useful information as well as an answer to your question on the "condition of your nerves" I am reaching out to you to find out if you would accept my response as a NEUROLOGIST. I am not a surgeon, however, believe am sufficiently and duly qualified to answer your question specifically on the "condition" of your nerves.

However, since I do not want to impose by offering a response that may not be of interest to you I am writing this to message first to discover if you will accept my answers based on this fact of my being a NEUROLOGIST and not a surgeon.

In the event you prefer to await a neurosurgeon or another orthopod to answer I completely understand. Then, what you can do is CLOSE this query and request a refund from HEALTHCAREMAGIC at which point you may repost your question without any financial loss.

Many thanks for your attention. I await your response.

---

Brief Answer:
State of the nerves

Detailed Answer:
Good evening. Many thanks for agreeing to accept my response and also thank you for your patience. I see you responded earlier today when I first sent the message but I guess I failed to make it clear that I was in the midst of going to my daughter's 3rd day of competition in the International Crossfit Games being held in XXXXXXX Italy in which she placed 2nd. Well, we were so proud that we told her that she could have dinner anywhere in the city that she wished. And since she's being on a strict diet for these competitions and has just worked herself to exhaustion to get to the podium...well, she just wanted to let go and have that famous PIZZA that Italy is known for....and so we are just coming back from that celebration. And so many thanks for your patience in responding.

Let me clarify a couple of things that may be a little confusing... the use of imaging studies in an acute traumatic situation resulting in a compression fracture of the lumbar spine in order to assess STATUS of nerves would not be possible. This is due to a phenomenon known as WALLERIAN degeneration which usually is not easily visible on scans to any extent for weeks to months. In other words, changes that occur at the level of the nerve roots or the peripheral nerves that are attached to those roots take WEEKS TO MONTHS to become VISIBLE on something like a CT scan or MRI.

By the way, these films do not appear to be MRI films to be. Rather, these are more reiminiscent of CT scan images. CT images when it comes to detecting nerve root or spinal cord compression is highly insensitive compared to MRI and that is because:

1. MRI is a much more sensitive imaging study to obtain when looking at SOFT TISSUES compared to CT SCAN which is typically used to look at bony architecture when talking about compression fractures, etc.

2. MRI scans done with gadolinium contrast can only really see TRUE nerve root compression by looking at the AXIAL IMAGE sets which are not seen in these files. You've provided AP/PA views (VERTICAL plane slices) as well as SAGITTAL views (profile/side VERTICAL SLICES). Doing AXIAL views of the spinal column and spinal cord (NOSE TO BACK horizontal plane views) are the necessary angles to image in order to see relevant anatomic structures.

Therefore, nothing can be said about the status of your nerves from the current CT SCAN images. Even though my colleague who previously answered you said that he could not see any significant compression of the spinal cord or nerves...is PROBABLY right based upon clinical judgement and criteria....but not because any of those structures are VISIBLE on the scans. In fact, neither the spinal cord or the nerve roots exiting the cord are not visible on any of the submitted images.

However, that does not mean there isn't a way of assessing the function of the cord and the nerves in order to determine if "damage" had been done to them as I believe you feel may have happened.

As far as what these images show. I am definitely in agreement that an L1 compression fracture appears on the scan and so I believe everyone agrees on that point. But there are also several vertebral bodies of the lower spinal column especially which show degenerative arthritic changes which were previous to the accident which may have been silent from a clinical perspective and then, become somewhat aggravated because the jolt you took in the accident but the changes that are evident and would be referred to generically as DEGENERATIVE ARTHRITIC CHANGES of the spine are not new, they are quite chronic and have been slowly getting a bit worse. Now, some of the symptoms you are having in terms of pain and numbness in the legs could be as a result of these SUBCLINICAL arthritic changes being accelerated into your conscious levels of pain and discomfort (numbness) as opposed to there being any acute "nerve damage." Make sense?

The most SENSITIVE and PRECISE way that any doctor could evaluate your NERVES that are in the spinal column or emanating from the spinal cord would be to perform an actual NEUROLOGICAL EXAMINATION on you which include a number of things such as muscle strength testing, sensory testing for pain, touch, temperature, proprioception, vibration, etc. This is through EXAMINATION of the person...not looking at an image.

Another way that FUNCTION can be assessed to a LIMITED extent (not as good as PHYSICAL EXAMINATION) would be to perform an EMG/NCV study. This will identify nerves that are not working at all or not working to full capacity. From what you state it would appear that most of the back pain you are experiencing is coming about as a result of weight bearing. This is not at all surprising since you have a compression fracture. Therefore, every time you move about, stand, or walk, you are putting your body's weight atop the LUMBAR #1 vertebrae which is cracked.

While it is true that there are surgical procedures to correct such a problem.....I as well as many neurologists agree that a conservative approach with physical therapy, exercise training, and pain management is ultimately the best course of action for any patient as opposed right away to SURGICAL resections and stabilitzations. Many neurologists including myself try and avoid invasive procedures if conservative ones have not really been tried yet.

While it is true that you seem to be having numbness in the legs....it needs to be decided through careful NEUROLOGICAL EXAMINATION which could involve the use of an ELECTRICAL STUDY (EMG/NCV) what is going on.

In short, if I were your neurologist working together with the surgeon...my recommendation would be that you undergo first and foremost a thorough NEUROLOGICAL EXAMINATION of the lower extremities by a neurologist so that the L1 nerves can be mapped out before doing anything invasively.

Secondly, and in the mean time, I believe you will continue to BENEFIT from PHYSICAL THERAPY and more than that, AQUATHERAPY which takes all the problems of gravity off your back and allows you to have much less pain when performing therapy sessions and that this approach be tried for a minimum of 3-6 months before seriously considering back surgery.

Third, if surgery were to be contemplated I would recommend that your neurologist confirm with your surgeon that the procedure to be performed would PREFERENTIALLY be a MINIMALLY INVASIVE procedure as opposed to an open radical procedure. This will minimize operative risks to the patient, minimize healing times, and theoretically, reduce pain status after the procedure.

Those are my thoughts on your status of neurological functioning which I believe is quite functional and so shall you remain in this way even with this L1 compression fracture. This can be "fixed" surgically at virtually any time if need be...but good conseravtive measures need to be tried first (even though they may be painful to some extent).

If I've provided useful or helpful information to your questions could you do me the utmost of favors by CLOSING THE QUERY along with a few positive words of feedback and maybe even a 5-star rating if you feel it is deserving? I am definitely interested in getting updated information on your condition if you'd care to drop me a line at www.bit.ly/drdariushsaghafi and let me know how things turned out.

You can always reach me at the above address for this and other questions. I wish you the best with everything and hope our discussion has aided in your understanding of a few concepts related to your concerns.

Regards
This query required 70 minutes of professional time to research, assimilate, and file a response.

---

Brief Answer:
State of the nerves

Detailed Answer:
Good evening. Many thanks for agreeing to accept my response and also thank you for your patience. I see you responded earlier today when I first sent the message but I guess I failed to make it clear that I was in the midst of going to my daughter's 3rd day of competition in the International Crossfit Games being held in XXXXXXX Italy in which she placed 2nd. Well, we were so proud that we told her that she could have dinner anywhere in the city that she wished. And since she's being on a strict diet for these competitions and has just worked herself to exhaustion to get to the podium...well, she just wanted to let go and have that famous PIZZA that Italy is known for....and so we are just coming back from that celebration. And so many thanks for your patience in responding.

Let me clarify a couple of things that may be a little confusing... the use of imaging studies in an acute traumatic situation resulting in a compression fracture of the lumbar spine in order to assess STATUS of nerves would not be possible. This is due to a phenomenon known as WALLERIAN degeneration which usually is not easily visible on scans to any extent for weeks to months. In other words, changes that occur at the level of the nerve roots or the peripheral nerves that are attached to those roots take WEEKS TO MONTHS to become VISIBLE on something like a CT scan or MRI.

By the way, these films do not appear to be MRI films to be. Rather, these are more reiminiscent of CT scan images. CT images when it comes to detecting nerve root or spinal cord compression is highly insensitive compared to MRI and that is because:

1. MRI is a much more sensitive imaging study to obtain when looking at SOFT TISSUES compared to CT SCAN which is typically used to look at bony architecture when talking about compression fractures, etc.

2. MRI scans done with gadolinium contrast can only really see TRUE nerve root compression by looking at the AXIAL IMAGE sets which are not seen in these files. You've provided AP/PA views (VERTICAL plane slices) as well as SAGITTAL views (profile/side VERTICAL SLICES). Doing AXIAL views of the spinal column and spinal cord (NOSE TO BACK horizontal plane views) are the necessary angles to image in order to see relevant anatomic structures.

Therefore, nothing can be said about the status of your nerves from the current CT SCAN images. Even though my colleague who previously answered you said that he could not see any significant compression of the spinal cord or nerves...is PROBABLY right based upon clinical judgement and criteria....but not because any of those structures are VISIBLE on the scans. In fact, neither the spinal cord or the nerve roots exiting the cord are not visible on any of the submitted images.

However, that does not mean there isn't a way of assessing the function of the cord and the nerves in order to determine if "damage" had been done to them as I believe you feel may have happened.

As far as what these images show. I am definitely in agreement that an L1 compression fracture appears on the scan and so I believe everyone agrees on that point. But there are also several vertebral bodies of the lower spinal column especially which show degenerative arthritic changes which were previous to the accident which may have been silent from a clinical perspective and then, become somewhat aggravated because the jolt you took in the accident but the changes that are evident and would be referred to generically as DEGENERATIVE ARTHRITIC CHANGES of the spine are not new, they are quite chronic and have been slowly getting a bit worse. Now, some of the symptoms you are having in terms of pain and numbness in the legs could be as a result of these SUBCLINICAL arthritic changes being accelerated into your conscious levels of pain and discomfort (numbness) as opposed to there being any acute "nerve damage." Make sense?

The most SENSITIVE and PRECISE way that any doctor could evaluate your NERVES that are in the spinal column or emanating from the spinal cord would be to perform an actual NEUROLOGICAL EXAMINATION on you which include a number of things such as muscle strength testing, sensory testing for pain, touch, temperature, proprioception, vibration, etc. This is through EXAMINATION of the person...not looking at an image.

Another way that FUNCTION can be assessed to a LIMITED extent (not as good as PHYSICAL EXAMINATION) would be to perform an EMG/NCV study. This will identify nerves that are not working at all or not working to full capacity. From what you state it would appear that most of the back pain you are experiencing is coming about as a result of weight bearing. This is not at all surprising since you have a compression fracture. Therefore, every time you move about, stand, or walk, you are putting your body's weight atop the LUMBAR #1 vertebrae which is cracked.

While it is true that there are surgical procedures to correct such a problem.....I as well as many neurologists agree that a conservative approach with physical therapy, exercise training, and pain management is ultimately the best course of action for any patient as opposed right away to SURGICAL resections and stabilitzations. Many neurologists including myself try and avoid invasive procedures if conservative ones have not really been tried yet.

While it is true that you seem to be having numbness in the legs....it needs to be decided through careful NEUROLOGICAL EXAMINATION which could involve the use of an ELECTRICAL STUDY (EMG/NCV) what is going on.

In short, if I were your neurologist working together with the surgeon...my recommendation would be that you undergo first and foremost a thorough NEUROLOGICAL EXAMINATION of the lower extremities by a neurologist so that the L1 nerves can be mapped out before doing anything invasively.

Secondly, and in the mean time, I believe you will continue to BENEFIT from PHYSICAL THERAPY and more than that, AQUATHERAPY which takes all the problems of gravity off your back and allows you to have much less pain when performing therapy sessions and that this approach be tried for a minimum of 3-6 months before seriously considering back surgery.

Third, if surgery were to be contemplated I would recommend that your neurologist confirm with your surgeon that the procedure to be performed would PREFERENTIALLY be a MINIMALLY INVASIVE procedure as opposed to an open radical procedure. This will minimize operative risks to the patient, minimize healing times, and theoretically, reduce pain status after the procedure.

Those are my thoughts on your status of neurological functioning which I believe is quite functional and so shall you remain in this way even with this L1 compression fracture. This can be "fixed" surgically at virtually any time if need be...but good conseravtive measures need to be tried first (even though they may be painful to some extent).

If I've provided useful or helpful information to your questions could you do me the utmost of favors by CLOSING THE QUERY along with a few positive words of feedback and maybe even a 5-star rating if you feel it is deserving? I am definitely interested in getting updated information on your condition if you'd care to drop me a line at www.bit.ly/drdariushsaghafi and let me know how things turned out.

You can always reach me at the above address for this and other questions. I wish you the best with everything and hope our discussion has aided in your understanding of a few concepts related to your concerns.

Regards
This query required 70 minutes of professional time to research, assimilate, and file a response.

---

Brief Answer:
Hoping for nothing but SUCCESS & QUICK healing in Wednesday's surgery

Detailed Answer:
I am very happy to hear that the explanation made sense....I was worried that writing it as late as night as it was would've caused me to be less clear than I wanted to make things.

I am also glad you found the comments relevant to your situation and I believe now you have MORE information from a NONSURGICAL perspective to make a more informed decision as to whether surgery is best for you or not. Since your procedure remains scheduled in the coming days this means you've considered all options and feel comfortable with the procedure.

Therefore, I am happy for your choice and wish you nothing but success. Equally happy to hear that the surgeon choice a MINIMALLY INVASIVE approach. Excellent choice of procedures for this sort of problem. With any luck you could virtually be into the rehabilitation phase within 24-48 hrs.

Please do not forget to ask your doctors for a recommendation to participate in AQUATHERAPY if available in your region. It is a very comfortable and EFFICIENT type of rehabilitation that patients such as yourself will find very accommodating and much more comfortable due to the buoyancy effects of the water which take so much of the bodyweight off the skeleton when doing things such as walking or RANGES of motion. Of course, your surgeon will give the strict parameters to your therapist of what is expected of you as you move forward after the surgery and it is all dependent upon how the repair aspect goes, etc. But, boy does that water feel good when patients finally get into the pool!

I have a final word on the sensation of numbness in the legs. If that becomes fully relieved after surgery then, nothing more to do or say about the symptom since obviously it was a direct consequence of the traumatic fracture of the L1 vertebral body. However, if any residual is left behind then, my next move as a neurologist would be to send you for blood work (if that already has not been done by your surgeon) looking for OTHER contributing factors to that symptom.

So for example, other things that can cause patients to feel numbness, tingling, or shooting pains into the legs (despite not having any of these symptoms prior to a trauma) would be chronic HYPERGLYCEMIA (Pre-diabetes), DEFICIENCIES in Vitamin B12, folate (less common), Vitamin D (VERY common even in people not symptomatic of anything), and LOW thyroid hormone levels (FT4 and TSH). These would be the TOP 5 things to look for in a patient with a complaint of numbness of the extremities...even if likely in association with a traumatic injury. I'm certain that they will screen you for the 1st problem as a matter of routine before the surgery. They MAY screen you for thyroid profiles as well (though they may only do a TSH...I recommend a FREE T4 as well to make the study as comprehensive as possible as a screener).

However, they may not actually run levels of your vitamins since this is highly overlooked by most surgical specialists who are focused on repairing traumatic injuries. My suggestion to patients undergoing surgery for nerve root decompressions, spinal column fractures, impingements upon the spinal cord, etc. is to get ALL of these items screened for since a deficiency or even low normal level in any one of them COULD lead to a more difficult time after surgery in recovery.

The reason is that if in fact, a SUBCLINICAL status of someting like HYPOvitaminosis or HYPOthyroidism becomes unmasked in a patient following a traumatic injury, hospitalization, or after surgical anesthesia, etc. -- now the patient faced with not only having to get over the immediate effects of the surgery and pain management but also the metabolic and pathophysiological effects of biochemical deficiencies which were not known to exist BEFORE and which are vital to the body's normal functioning.

Again, the concept of screening for such things or least being aware of the possibilities they could exist is not something that is often taken into consideration just before surgical procedures but in my opinion, if done more frequently and routinely would likely lead to much better outcomes in patients who are otherwise, just left complaining of ongoing symptoms of numbness, tingling, pain, etc. And after a while it is merely assumed that these symptoms must simply be complications from surgery or complications from the trauma itself and patients AND DOCTORS go on thinking there's not much to do except prescribe more medications to try and control symptoms when in fact, the cure and control lie in more basic underlying reasons and mechanisms that are relatively easy to identify and fix at any time....just gotta think a little more vertically than we have in the past when surgeries focused on fixing exactly what was broken without realizing that other things (less obvious) may have broken at the same time and are not DIRECTLY a result or consequence of the initial traumatic injury. Hope that makes sense. And I hope you have NONE of these complications I'm talking about but they are things to remember if you get to a point where some symptoms come about or continue that you thought were going to be ameliorated by the repair of that fracture but for some reason don't seem to be coming around.

That's when you either call your friendly neighborhood NEUROLOGIST....or get back in touch with me on this network or in my office should you happen to just be going by the region of XXXXXXX OHIO, USA....HA! And when talk about things again.

At any rate, those are my final thoughts on the subject and I will now leave you again with the high hopes and expectations that you will enjoy a full and speedy recovery from your upcoming surgery. I on the other hand am planning to enjoy the rest of this trip in XXXXXXX with my wife and daughter who has just accomplished some very terrific things and deserves to buy a little gift or 2 for herself in the City...so I'll sign off at this time.

Again, just a reminder that if I've given you any additional information of value or insight to your problem would you consider CLOSING THE QUERY and add just a few positive words of feedback with a 5-star rating if worthy? I am very interested in getting updated information on your condition if you'd care to drop me a line at www.bit.ly/drdariushsaghafi and let me know how things turned out.

You can always reach me at the above address for this and other questions. Cheers and good health be with you!

Kindest Regards--

This query required 115 minutes of professional time to research, assimilate, and file a response.

---

Brief Answer:
Hoping for nothing but SUCCESS & QUICK healing in Wednesday's surgery

Detailed Answer:
I am very happy to hear that the explanation made sense....I was worried that writing it as late as night as it was would've caused me to be less clear than I wanted to make things.

I am also glad you found the comments relevant to your situation and I believe now you have MORE information from a NONSURGICAL perspective to make a more informed decision as to whether surgery is best for you or not. Since your procedure remains scheduled in the coming days this means you've considered all options and feel comfortable with the procedure.

Therefore, I am happy for your choice and wish you nothing but success. Equally happy to hear that the surgeon choice a MINIMALLY INVASIVE approach. Excellent choice of procedures for this sort of problem. With any luck you could virtually be into the rehabilitation phase within 24-48 hrs.

Please do not forget to ask your doctors for a recommendation to participate in AQUATHERAPY if available in your region. It is a very comfortable and EFFICIENT type of rehabilitation that patients such as yourself will find very accommodating and much more comfortable due to the buoyancy effects of the water which take so much of the bodyweight off the skeleton when doing things such as walking or RANGES of motion. Of course, your surgeon will give the strict parameters to your therapist of what is expected of you as you move forward after the surgery and it is all dependent upon how the repair aspect goes, etc. But, boy does that water feel good when patients finally get into the pool!

I have a final word on the sensation of numbness in the legs. If that becomes fully relieved after surgery then, nothing more to do or say about the symptom since obviously it was a direct consequence of the traumatic fracture of the L1 vertebral body. However, if any residual is left behind then, my next move as a neurologist would be to send you for blood work (if that already has not been done by your surgeon) looking for OTHER contributing factors to that symptom.

So for example, other things that can cause patients to feel numbness, tingling, or shooting pains into the legs (despite not having any of these symptoms prior to a trauma) would be chronic HYPERGLYCEMIA (Pre-diabetes), DEFICIENCIES in Vitamin B12, folate (less common), Vitamin D (VERY common even in people not symptomatic of anything), and LOW thyroid hormone levels (FT4 and TSH). These would be the TOP 5 things to look for in a patient with a complaint of numbness of the extremities...even if likely in association with a traumatic injury. I'm certain that they will screen you for the 1st problem as a matter of routine before the surgery. They MAY screen you for thyroid profiles as well (though they may only do a TSH...I recommend a FREE T4 as well to make the study as comprehensive as possible as a screener).

However, they may not actually run levels of your vitamins since this is highly overlooked by most surgical specialists who are focused on repairing traumatic injuries. My suggestion to patients undergoing surgery for nerve root decompressions, spinal column fractures, impingements upon the spinal cord, etc. is to get ALL of these items screened for since a deficiency or even low normal level in any one of them COULD lead to a more difficult time after surgery in recovery.

The reason is that if in fact, a SUBCLINICAL status of someting like HYPOvitaminosis or HYPOthyroidism becomes unmasked in a patient following a traumatic injury, hospitalization, or after surgical anesthesia, etc. -- now the patient faced with not only having to get over the immediate effects of the surgery and pain management but also the metabolic and pathophysiological effects of biochemical deficiencies which were not known to exist BEFORE and which are vital to the body's normal functioning.

Again, the concept of screening for such things or least being aware of the possibilities they could exist is not something that is often taken into consideration just before surgical procedures but in my opinion, if done more frequently and routinely would likely lead to much better outcomes in patients who are otherwise, just left complaining of ongoing symptoms of numbness, tingling, pain, etc. And after a while it is merely assumed that these symptoms must simply be complications from surgery or complications from the trauma itself and patients AND DOCTORS go on thinking there's not much to do except prescribe more medications to try and control symptoms when in fact, the cure and control lie in more basic underlying reasons and mechanisms that are relatively easy to identify and fix at any time....just gotta think a little more vertically than we have in the past when surgeries focused on fixing exactly what was broken without realizing that other things (less obvious) may have broken at the same time and are not DIRECTLY a result or consequence of the initial traumatic injury. Hope that makes sense. And I hope you have NONE of these complications I'm talking about but they are things to remember if you get to a point where some symptoms come about or continue that you thought were going to be ameliorated by the repair of that fracture but for some reason don't seem to be coming around.

That's when you either call your friendly neighborhood NEUROLOGIST....or get back in touch with me on this network or in my office should you happen to just be going by the region of XXXXXXX OHIO, USA....HA! And when talk about things again.

At any rate, those are my final thoughts on the subject and I will now leave you again with the high hopes and expectations that you will enjoy a full and speedy recovery from your upcoming surgery. I on the other hand am planning to enjoy the rest of this trip in XXXXXXX with my wife and daughter who has just accomplished some very terrific things and deserves to buy a little gift or 2 for herself in the City...so I'll sign off at this time.

Again, just a reminder that if I've given you any additional information of value or insight to your problem would you consider CLOSING THE QUERY and add just a few positive words of feedback with a 5-star rating if worthy? I am very interested in getting updated information on your condition if you'd care to drop me a line at www.bit.ly/drdariushsaghafi and let me know how things turned out.

You can always reach me at the above address for this and other questions. Cheers and good health be with you!

Kindest Regards--

This query required 115 minutes of professional time to research, assimilate, and file a response.

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