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Dear Dr Corenman,
Thank you for this site, I have found so much useful information regarding my condition and you provide such detail! I have found myself in a rather undesirable circumstance and am very confused as to my next move.
I have had two L5/S1 discectomies within six weeks of each other as the first one must have re-herniated very shortly after the first surgery. I am 3 months post second surgery and have the following symptoms:
– pain after sitting for 20 minutes in my right leg
– some throbbing pain when standing and walking primarily in my hamstring and calf
– neural tension- any flexion of the hips and neck causes a sharp shooting pain down my leg
– Pins and needles in my footMost of the time I can alleviate the symptoms by a comfortable laying position. I am on 900mg of gabapentin a day but cannot work or live a normal life currently.
My MRI result today revealed the following:
Small residual disc protrusion at L5/S1. Although this contacted the right S1nerve root sheath, it does not appear to displace or compress the nerve root. Prominent enhancement persists around the right S1 nerve root which presumably represents post operative granulation tissue. There is a slight enhancement around the proximal portion of the L5 nerve root.
What would you advise I do to try to reduce the symptoms I have and what does this granulation mean? I am currently doing PT, hydrotherapy, massage and acupuncture, building my core etc. I have had one periradicular nerve block but at the S1 level as they said it was too risky injecting at the L5,S1 level. I am so worried that these symptoms will set in for life…
Your help is much appreciated,
Hopeful ( Jess)
You have had two microdiscectomies at L5-S1 for recurrent disc herniation. Recurrent disc herniations are not uncommon. They occur about 10% of the time, even immediately after the initial surgery as in your case.
Post-operative granulation tissue always occurs after a spine surgery. This is Mother Nature’s way of healing the area but this healing tissue will cause some scar tissue in some cases. This might be what has happened to you but other possibilities are root damage (chronic radiculopathy-see website) or the small recurrent HNP can be trapping the root when associated with this scar tissue.
One other possibility is foraminal stenosis along with the original radiculopathy. This would affect the L5 nerve (the S1 nerve is the one originally affected by the herniation at this level). This diagnosis is possible because of one of your symptoms (“some throbbing pain when standing and walking primarily in my hamstring and calf”). This diagnosis is unlikely however.
With these symptoms, I think I would consider a TFESI (transforaminal epidural steroid injection-see website) at the L5-S1 level. You might need as many as three to reduce inflammation. If that does not work, a careful examination of your images would lead to the next step.
Dr. Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.Thanks so much Dr Corenman! Wish I could book an appointment with you but I am all the way over in Australia. Your reply provides some possibilities to consider.
Am I correct in saying that scar tissue is irreversible? I.e. Can steroid break it up? And if not, does the nerve root ever adapt to a new environment of scar tissue surroundings? I can be sure that there is something stopping the nerve from moving as my flex ion accompanied with my neck drop or slump test is positive-especially in the morning and it eases as I become mobile.
This does not however explain pain when sitting, which is most irritating. As a MRI Images the spine when laying with little pressure placed on the discs, could it be that the pressure from sitting causes that small disc protrusion to then push on the nerve and start to irritate it?
Post second operation, I had 10 days of pain relief and the the pain started to come back gradually. I will seek out an injection as you suggest. Should I be trying to move that tissue? Walking, swimming, stretching, massage, traction, neural tension exercises, TENS etc or should I be lying low trying not to feel any pain. It seems there is a fine balance.
Many thanks for your expert advice!
:-)
Scar tissue always occurs in the face of surgery but normally is not a problem with continued symptoms. If for some reason the granulation tissue is intense, this can form significant scar that can tether the nerve root.
This is why “nerve flossing” is performed about 10 days out from a microdiscectomy. Nerve flossing is simply the same thing as a hamstring muscle stretch. The action moves the nerve in the canal and prevents adhesions from tethering the nerve root.
Sitting causes nerve root stretch as the spine is flexed on the pelvis. This position elongates the nerve root and if there is a mass in front of the nerve (disc herniation), this will cause compression of the root and leg pain. If the nerve is swollen or irritated, sitting will also cause leg pain.
You should consider trying to stretch the root with hamstring stretches but not so much as to aggravate the root. This is the art of medicine and not the science of medicine.
Dr. Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.Thanks for the information!
I have noticed that sitting in a yoga style position does not cause pain so I think I can eliminate the disc being a problem. I can feel when taking long strides that the nerve is irritated and on tension. If inflammation is an issue, can you recommend anything to reduce it besides an steroid injection?
Since the second operation, I have been active and flossing the nerve. I am just confused as to whether this has inflamed the root and therefore I should back off the activity or adhesions are occurring and therefore I should keep active and moving (and how am I supposed to know which scenario is the problem)
Thanks Dr Corenman!
Pain should be your guide. If the nerve flossing is aggravating your nerve (increased pain), back off. If there is no change, continue your nerve glides.
Yoga sitting position does cause hip flexion (bending of the hip) but also includes knee flexion, Knee flexion will reduce the stretch of the nerve so this position is not too helpful in determining if the nerve is stretched into a herniation.
If the nerve is inflammed, oral steroids or even NSAIDs (Motrin and Aleve) can be helpful.
Dr. Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books. -
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