11 weeks of back pain and sciatica, looking for advice on next steps

Tagged: Lumbar disc hernation and questionable weakness

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MPPotter
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October 4, 2016 at 5:09 pm

Post count: 4

#23140

Hi Dr Corenman,
I was hoping you could give me some advice on how to proceed.

History

I’m a 34 year old male, 5’11”, overweight (108 kg), sedentary job and life style.
I have had intermittent lower back pain in the past, however 11 weeks ago I had a sudden onset of central lower back pain. I was functional, but extremely stiff after driving to work.

Over a two week period the pain shifted to the left buttock/thigh. At this time I attended a physiotherapist, and started doing lying McKenzie extension exercises (which helped somewhat with the pain) plus other core strengthening exercises prescribed by my physio. I also started walking two or three times a day.
Soon after this I began getting pins and needles on the outside side of my calf. At it’s worse I had periods (usually only an half our or so) of complete numbness of the two outside toes (they felt like leaden weights on my foot). A GP examination of my reflexes at this time showed no loss of reflex and I don’t believe I have any leg weakness.

Pain and neurological symptoms peaked at the birth of my son 5 weeks ago (I’m assuming due to stress levels and additional demands on my body) and have now settled somewhat. On my GP’s advice I started taking 400mg ibuprofen three times daily (I am tolerating it well) and 30mg codeine when needed (say for an event), a few times a week, never more than once a day.

At this point I have significant sciatic discomfort driving in to work in the morning, but am can move more freely more quickly once there, and my discomfort is significantly less when driving home in the evening. Sitting for long periods or in the wrong chair is still problematic (I use a standing desk now mostly at work) and my pain seems to increase at night after lying. I don’t wake in pain but I do find it hard to get comfortable again and go back to sleep when I do wake, which is frequently with a newborn. I’m probably losing around 2 hours of sleep a night.

Pain decreases significantly to mild discomfort when I’m lightly active (walking, tidying the house etc) and distracted. Extended walking can flare things up after, but if I lie propped up on elbows for half an hour or so most symptoms settle down.

MRI results

I had an MRI done last week, which revealed the following (I’ve paraphrased):
Vertebral body height and signal maintained at all imaged levels. Transistional vertabra at lumbosacral junction treated as lumbarised S1 for report. Conus terminates at L2.

l4/5: Small generalised posterior disc protrusion, slightly more prominent right paracentral component. Associated annular fissure/tear. Both exit foramina are patent. Mild narrowing of facet joints.

L5/S1: Focal, large posterior disc protrusion, most pronounced in the left posterolateral position but extending from right posterolateral to left posterolateral. Moderately high grade stenosis of the canal, particularly on the left. Compression of the traversing left S1 nerve root. No significant foraminal narrowing, l5 nerve roots exit freely. Minimal degenerative changes of facet joints.

S1/2: No significant space occupying disc lesion. Canal and both foramina are patent.

Questions

My GP has referred me for a spinal epidural injection which I have scheduled, but ideally I’d like to speak to a specialist. Under the public health system in Australia I will be looking at probably a year’s wait to have surgery after seeing a specialist, based on my relatively milder symptoms.

In your opinion, should I insist on a referral to see a spine specialist at this point?
Is an epidural a reasonable next course of action?
Am I likely to do permanent damage to my nerves by putting off surgery?
How long should I pursue a conservative approach before seeking surgery?

Thanks very much for your time, any advice is appreciated.

Donald Corenman, MD, DC
Moderator

October 9, 2016 at 6:05 am

Post count: 8660

#23160

You have a perfect history for an L5-S1 disc hernation. These disc hernations start with an annular tear which causes central back pain. As the disc herniates, the nerve becomes compressed but will take 1-3 days to develop leg pain. The nerve is tented by the disc herniation so sitting (or bending forward) hurts and standing is better (the nerve is under less stress when your thigh is parallel to your back-standing).

I would be suspicious of your GP’s finding that your reflexes are equal. Almost always with the size of your hernation, the left achilles reflex will be dulled (plus one instead of plus two) but it is a subtle art to determine what the reflex is.

One of the keys is to check the strength of the gastroc-soleus (calf) muscle. This muscle is so strong that manual testing (the doctor uses his own strength to see if he can “break” the muscle) normally is useless so there is a self directed test that can check the strength. See https://neckandback.com/conditions/home-testing-for-leg-weakness/ to understand how to test the S1 nerve.

If you have no motor weakness, I normally advise an epidural steroid injection along with PT. These injections can be very helpful to relieve pain. If the injection helps, then a repeat injection might be helpful in 2-4 weeks.

If however, the muscle is weak, I recommend surgery as the chance of motor strength recovery is much less without surgery than with surgery. I understand this is a national health care country but they should be able to do the right thing. I have talked to prior Australians with this same problem. These individuals were successful (if their GPs would not emergently refer them for a surgery) by presenting themselves to an ER with pain and weakness. The ER tends to understand this dilemma and ask for a quick referral.

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.

MPPotter
Participant

October 9, 2016 at 9:18 am

Post count: 4

#23164

Thanks Dr,

Really appreciate you taking the time, you are a scholar and a gentleman.

I stumbled across your strength test page after originally posting and have been amusing my colleagues my stalking the halls at work on my tippy toes. My heel doesn’t seem to drop at all, though I do seem just very slightly slower doing 20 stationary heel raises in a row on the effected leg than my other. I was able to do several sets in a row though.

Just one other question regarding the leg pain I’ve noticed – when I get up at night after lying for few hours, I have minimal initial pain or anything while remaining lying, but after standing for a about a minute or two I get a rush of pins and needles and bad sciatic pain that I need to “walk through” for 10 minutes. This is the worst my pain gets. Just wondering what prompts that response, is it something I can prevent through sleeping position or just a result of increased inflammation over night while stationary?

The ER tip is a good idea thanks. I don’t have a lot of faith in my GP, he’s the one always available for appointments at his practice. My sister is a great GP but sensibly is hesitant to treat or refer family.

Donald Corenman, MD, DC
Moderator

October 9, 2016 at 9:32 am

Post count: 8660

#23165

Great that you have no motor weakness. This means that pain is the only indication for surgery. I would try the epidural and would expect good results. About 70% of patients without motor weakness can avoid surgery by this injection.

Normally, patients have immediate worsening pain when getting up after sleeping but an occasional patient has not only disc hernation pain but also has lateral recess stenosis pain. This is just a variant of the HNP pain complex and does not mean much in treatment.

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.

MPPotter
Participant

October 9, 2016 at 3:04 pm

Post count: 4

#23168

Thanks again!

My injection is tomorrow so I’ll see how that goes, and push for a referral if I see no improvement in a week or two.

Donald Corenman, MD, DC
Moderator

October 9, 2016 at 9:26 pm

Post count: 8660

#23171

Let us know your progress please.

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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Donald Corenman, MD, DC

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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