Who is BU: Physios or GP/consultant?

[LittleGreyFluffyCat]

Medical professionals are disagreeing about my MRI results:

GP & spinal consultant say: 'Normal wear and tear, wouldn't cause any symptoms'
Physios x2 say: 'Not a negative MRI, would definitely cause your symptoms'

^MRI says:
Mild spondylotic changes at C5-C6 and C6-7 levels. There is mild osteophytic encroachment of bilateral neural foramina at C5-C6 level causing mild impingement of bilateral exiting nerve roots. Bilateral neural foramina are minimally compromised. The spinal canal is adequate.^

YABU: GP & spinal consultant correct
YANBU: Physio is correct

I've had ongoing symptoms (worsening arm pain, tingling around neck and back, pain in back near arms) for over a year. I can't get help unless a GP or consultant agrees with the physio point of view. I can afford one more private consultation with a new spinal consultant but don't want to waste £££ if the physios are just talking nonsense.

Posting this in the desperate hope a medical person or two will see this and have a helpful opinion.

I would say that it would for some people and not for others

Your scan is borderline not barn door abnormal. It's a grey area. It might be normal wear and tear and just an incidental finding and not the cause of your symptoms or it might be the cause. These things are a matter of opinion and opinions vary. It's not a yes/ no black and white thing. Frustrating but true
That why I hate it when people think scans can provide a definitive answer when often they can't. It's about clinical context too.
A scan can be completely normal and rule things out or completely abnormal and obviously show a cause but many many scans can be in a grey area of showing some abnormality but not normal necessarily a causal one.

If you shop around and pay then eventually you will find someone willing to agree that this is the cause but that doesn't mean it actually is. In fact no one knows.

If you want surgical intervention then you have to find a surgeon who will do it. Spinal surgery is notoriously variable in outcome, can be dangerous and is often not the answer. there is a pretty high failure rate.

You may be better off to stop chasing a definitive answer about the cause and focus on what relieves your symptoms

@Flyingbymypants Interesting - what's your job?

I'm sure I've "spoken" to you on there as I'm from medway myself.

@CovoidOfAllHumanity argh that is so depressing. The only thing that relieves my symptoms is not doing much with my arms, which is obviously quite impractical.

@Iamaslummymummy - probably! :-)

I had something similar when very young. TBH I have no clue what the real diagnosis was, but I got rid of it with a combination of osteopathy and pilates.

Comes back every so often, I do a bunch of Pilates and it goes.

@CovoidOfAllHumanity really interesting post by the way, what's your job?

It's not that I want surgery, it's more that I'd like to know what I'm dealing with. TOS gets progressively worse and there are things (e.g. swimming, driving, typing) that will definitely make it worse and certain physio exercises that might make it better. Whereas cervical nerve impingement might benefit from gentle traction and will probably need different physio exercises, and perhaps isn't going to get worse if I swim, drive or type.

Ideally I'd know what I'm dealing with so I can do whatever makes it better and not do things that make it worse. And so I can look up a physiotherapist who understands whatever condition I've got and get help from them.

Surgery would be a last resort, it's definitely not what I'm seeking. I'd be interested to see if injections helped - as a diagnostic tool so I know where in my body the problem is.

I was about to ask if you were hyper mobile by any chance, and then saw your reply.

Not medically trained but do have HMS. Couple of points worth considering:

1. Hypermobility is not always in the typical joints. The Beighton Score is the usual tool to assess degree of hyper mobility (i.e. how widespread), but it only works if you have hyper mobility in the joints measured on the Beighton Score. Personally I have non-typical joints affected so although my Beighton Score is low, my physio and a consultant who looked into this in more detail could see easily that in some of my joints I have extreme hyper mobility. Neck hyper mobility isn't measured on the BS.

1. Because your neck joints are potentially very mobile, their position can change, and so certain positions, or period where joints aren't quite in the right place, can result in the kind of symptoms you mention, but won't necessarily show on an MRI when you're flat on your back. After things like little knocks or braking the car too hard, I've had 'worrying' symptoms like you, suggesting disc issues, but my discs are pretty good, and the issue has been the joint has moved and is pressing on the nerve, causing the symptoms. What we do now is have an MRI to check I haven't seriously damaged a disc/threatened a nerve etc, and then once that's fairly clear, the physio works to put things back where they belong. They don't always stay there of course!

@Pollaidh very interesting thanks for posting. Where in the country is your physio? He/she sounds amazing!

I'd be looking at here if you're close enough. There's so much that can come from being "a bit bendy". I'm wondering HOW bendy, and if it is HMS or if its actually something more. I'd be trusting the physio's gut, and you know yourself that something isn't right (your arm isn't meant to do that, so something's gone wrong somewhere!)

www.thelondonhypermobilityunit.co.uk/

I suspect there is an element of miscommunication- that does read to me as though the scan reports really quite mild/early changes caused by “wear an tear”, which is in and of itself a normal process, and so not an “unexpected” finding, as such- unless you are 21 or something- it does depend somewhat on age as to whether this is “premature” or “early onset” or something we might expect to find. These mild changes do happen to some earlier/more severely than others for a whole variety of reasons.

However, if you took a random sample of people mid 30’s/40 and upwards you could well find these or similar changes in quite a few people and some changes in most scans, but of those people with abnormal scans many will have few (perhaps a bit if stiffness, for example) or no symptoms at all. This is why scans are not always 100% conclusive- just because you see something on a scan does not mean it is the cause of a symptom (confusingly, even if it theoretically has the potential to). You have to correlate symptom, examination findings with scans (and any other investigations).

It means that it is possible that the mild impingement of the exiting nerve roots is the cause of your pain, but from the severity and pattern you describe I’m afraid equally possible that there is another cause (impingement or nerve irritation below the level of nerve root, muscular problems, peripheral neuropathy etc), or that the changes are contributing but not the sole cause.

And then you have the issue of “can anything be done?”- if you go to a spinal surgeon they will see that level of mild change and- rightly- say “no surgical target”, i.e. there is no way surgery will help and may make things worse.

It is not unusual to see patients coming with radiculopathy symptoms (nerve impingement causing pain, change in sensation/ tingling/pins & needles/ numbness etc) and changes/nerve impimgement/disc issues on a scan but find analgesia and passage of 6 weeks, possibly some physio, and symptoms really settle down. But if you rescanned them those changes would still be there, yet symptoms gone or are now minimal. In these cases muscular/soft tissue issues can be contribute to, or exacerbate, any wear and tear/disc issues, or even be the principal issue.

Hard to say in your specific case, but if in doubt you are entitled to a second opinion.

@rainbowzebra05 Thanks for that link, is there a particular rheumatologist he recommend from there?

@jacks11 Thank you for explaining all that, your post in the post of others have been helpful, I understand better now that it isn't so black or white.

You seem like you have medical knowledge.

Do you mind me asking what your job is?

[quote LittleGreyFluffyCat]@rainbowzebra05 Thanks for that link, is there a particular rheumatologist he recommend from there?[/quote]
Prof. Graham but I think he might have retired. The whole team there are fab though :)

@rainbowzebra05 thanks

I'd say they're all right in their way too.

For someone 50+ mild spondylosis is part of the aging process sadly and would be wear and tear. That's not to say you don't suffer or have symptoms but it wouldn't trigger an intervention from a spinal specialist, certainly not surgery.

Osteophytic encroachment means that your vertebrae (on a scan or x-ray they look like squares, despite being cylindrical) have little bits of bone sticking out at the edges which will push on nerves and may cause impingement or irritation, there may be something a physio could do, I don't know enough about physiotherapy to comment but trust their judgement and knowledge.

As pp have said imaging doesn't always give a definite answer and it is down to the clinician deciding a plan for the patient by weighing up all the pros and cons for different treatment.

So for the spinal surgeon, they see cases so much more advanced, your report they've dismissed as mild/wear n tear. The risk of any treatment they could offer like surgery would be too high compared to any benefit you may receive. So surgery is too risky to try for a mild case.

The physio knows that you have symptoms and that they are likely to be caused by the osteophytes. They aren't wrong.

The thing for you to concentrate on is how to ease the symptoms. It may be that you need to explore a different route and you've had some good advice and suggestions to take forward.

My physio is not in the SE unfortunately. I'd tend to avoid sports physios (they can be quite brutal which isn't great with HMS), maybe search for physios with an interest in hypermobility, or phone a few and ask.

To start - I'm not in any medical field.

From my experience, I was told repeatedly my issues were muscular, no real explanation for my symptoms, and I ended up having surgery for nTOS. I was told by 2 consultants there wasn't an issue but they still couldn't explain my symptoms. Eventually found someone who got to the bottom of what was going on, and it was severe enough to require surgery.

It was a lucky encounter with a physio with an interest in hypermobility who set me on the path for diagnosis.

I'm not based anywhere near you but would happily share more details by PM as it may be worth travelling to see someone who's a real expert in TOS. Obviously I don't know whether that's what you've got, but it might be worth exploring a little further so you can definitively rule it out.

Scans are poor indicators of pain. As previous posters have said, pretty much everyone’s scans will show something “abnormal”, but symptoms don’t always correlate. I’d ask to be referred to a pain management service. Pain relieving medication doesn’t help a great deal in persistent pain conditions, it’s about finding self management strategies to live well and reduce the impact of pain. There’s lots of information here www.flippinpain.co.uk/ (I work in a pain management service)

Thanks everyone. I've got Covid so will come back to this thread when I feel better.