Guidance for accepitng situation or pursuing a solution. L5/S1 post-op pain.

First-do you have more leg pain standing and walking or sitting? Sitting pain is typically associated with a disc hernation and standing with lateral recess or foraminal stenosis. This makes a difference when interpreting the MRI findings and X-rays which should include flexion and extension views.

There are times that the surgeon and radiologist might misinterpret images so another set of eyes (a second opinion) would be something to consider.

Interestingly, I just took care of a pro skier who had a prior disc hernation 1 1/2 year ago with a successful microdisectomy and great relief of leg pain at that time. He had acute onset of new but recurrent leg pain (same leg pain as from the prior herniation but with a year of no pain in-between episodes). The MRI noted no evidence of new herniation but just the typical “scar” tissue.

He acted just like a new disc herniation with all the typical symptoms and exam findings. I told him I would surgically neurolyse the nerve (free it from any adhesions which can sometimes fix the nerve in place and generate pain). Much to my surprise, when I freed up the nerve root, there was a relatively large disc hernation sequestered under this root. I removed it and the patient had 100% relief of his leg pain and is back to professional skiing.

I normally “believe” the MRI but I went back to this imaging study and reviewed it with my radiologist. We both agreed that there was no obvious disc herniation so great care needs to be taken when reviewing all the data (including patient history, examination and imaging.

If you have pain with standing and walking, this is a different but related problem. The disc can collapse after a hernation and narrow the foramen or the lateral recess (see the website to understand these conditions). Pain will be generated by standing and walking and be relieved with sitting or lying down.

If both situations are disproved so there is no mechanical compression of the nerve ether with standing or sitting, you certainly could have chronic radiculopathy (nerve injury that might not heal). There are medications and implants that can be considered (spinal cord stimulators or peripheral nerve stimulators).

Dr. Corenman

You have classic symptoms of an S1 radiculopathy. The fact that there is no activity that consistently will aggregate your pain could yield some evidence of the presence of a chronic and not of compressive radiculopathy.

The stand-up MRI is not worth the time and money as their images are poor and generally unhelpful.

Delayed onset leg pain with squatting maneuvers does not differentiate the diagnosis of compression vs. chronic injury.

You could consider a CT myelogram to have another tool to visualize your nerve root. It can help with diagnosing the cause of the nerve irritation.

Dr. Corenman

Unfortunately, physical conditioning does not bare any weight or chronic nerve root injury.

Yes, over time this condition can improve but by small increments.

Coping with this chronic pain is interestingly, both more and less difficult for an athlete. Athletes are conditioned to ignore pain so they are generally more pain tolerant. However, activity that stretches the nerve root (most athletic activities) will trigger more pain.

I would make sure there are no adhesions or compression based upon the MRI (with the caveat noted above). If there are no indications to explore the root surgically, then management is necessary. This includes medication (see this section on the website) which involves membrane stabilizers and NSAIDs.

Finally, a spinal cord stimulator or peripheral nerve stimulator can be considered the “final” treatment pathway if nothing else is effective to reduce pain.

Dr. Corenman