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#28472

Hi Dr. Corenman,

I am currently 8 weeks post-microdiscectomy surgery for a 1.7cm herniation of my L5-S1 disc that was significantly crushing my left S1 nerve root and creating a substantial lateral shift of my torso. I have had a fairly positive recovery so far but am a bit concerned however with a sharp pain in my lower back and left buttock which is aggravated by being on my feet for extended periods. When I initially stand up from being seated or lying down there is no pain, but over a 10-15 minute period I start to experience mild pain and discomfort deep in my left buttock above the gluteal fold, and it will eventually begin to radiate into my back increasing in intensity after 15 minutes. Occasionally I feel a bit of mild pain and altered sensation in my hamstring, ankle, and 4th and 5th toes which were completely numb or in excruciating pain prior to the surgery. I don’t get any numbness or pins and needles at this point.

If I remain on my feet for more than approximately 30-40 minutes, i will becoming increasingly more uncomfortable and when I sit down again there will be a sharp, stabbing pain in my buttock that I would rate as approximately a 7-8/10. After approximately 30 seconds it is completely gone and I am comfortable when seated and if I stand up again the cycle will repeat.

At this point in my recovery, I can sit comfortably, have a normal stride while walking, and have been increasing my flexibility towards a normal range through PT. I’m actually feeling quite good with the exception of being unable to stand for more than short periods of time. One thing worth mentioning is that for the first 3 weeks after surgery, I could stand comfortably for hours with no issues. This current problem has been affecting me for the last 3 weeks or so.

I’m hoping to return to my job as an airline pilot as soon as possible, but need to regain normal function of my body to pass an aviation medical. I’m trying to determine if this is a nerve issue that may require time to heal, or if it may be muscle or joint related.

Any insight you may be willing to offer would be much appreciated.

Thanks in advance.

I had a followup appointment with my neurosurgeon, and he really didn’t have much to say about it. He did mention that during the surgery he bathed the compressed nerve in steroids as it was in pretty rough shape.

Any feedback you might have would be much appreciated. I’m trying to determine if this may be nerve root irritation

[Donald Corenman, MD, DC]

#28490

With such a large herniation, you could expect to have some significant root injury. This will take some time to resolve (up to 6 months). There is the possibility that you have developed a seroma (a collection of fluid) that is compressive. The other possibilities are a recurrent herniation (not probable based upon symptoms) or foraminal/lateral recess stenosis as the disc height has diminished due to loss of “cushion” which can make the canal more crowded. Your symptoms do fit with stenosis (more pain with standing relieved by sitting). See https://neckandback.com/conditions/lumbar-foraminal-stenosis-collapse/ and https://neckandback.com/conditions/lateral-recess-stenosis/

The first step in my practice is to put the patient on a 5 day course of oral steroids. If that does not work, the next step is a new MRI. If there is a seroma, I have it aspirated and a steroid epidural placed. IF recurrent herniation but not too big, an epidural is also used. If large enough, a redo microdisectomy is considered. If stenosis, again try an epidural initially.

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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#28495

Thanks for the reply Dr. Corenman,

I thought of some additional information that I could include that may be relevant. In the first 3 weeks of my post-surgical recovery, I had absolutely no issues standing for extended periods of time. I could have stood comfortably for hours at the time as I was trying to avoid too much sitting. My neurosurgeon had applied steroids to the nerve during the surgery as my nerve was quite compressed and ‘beat up’ in his opinion. Around the 3-4 week mark, I began to notice my intolerance to standing, and it gradually worsened to the point it is at now. I don’t believe it is getting any worse at this time. I find that it is less noticeable when walking, and I can walk with little discomfort for approximately 45 minutes. I still find standing for more than 15-20 minutes to be uncomfortable however.

I reviewed my 2 MRI reports from before the microdiscectomy. Both MRIs indicated normal spinal alignment, and that intervertebral disc spaces were preserved. My first MRI taken over a month before surgery noted a large paracentral disc extrusion contributing to moderate canal stenosis on my left side where it was impinging my s1 nerve root. Additionally, it was causing mild bilateral foraminal narrowing.

My second MRI taken a month later immediately before the surgery noted a mild disc bulge with the superimposed large disc protrusion. At this point it was assessed as causing mild right, and mild/moderate left neuroforaminal narrowing.

I guess my next question is regarding this foraminal narrowing. My MRI images noted that there was no significant narrowing at any other levels in my lumbar spine with the exception of the L5-S1 level where the bulge and herniation were present. Would my microdiscectomy have cleaned out and improved this foraminal narrowing, or is it something that could still be present at that level? Is foraminal narrowing or stenosis common to see in an otherwise healthy 35 year old male? I’m wondering if perhaps my left nerve root is inflamed or swollen and is giving me symptoms due to the fact that there is no longer as much space on that side between my vertebrae and am wondering whether it could become asymptomatic if I can get the inflammation down.

Another point of interest is that prior to my surgery, the only position that would provide me any relief from my leg pain and numbness was to put my back into extension. I would guess that this would mechanically make things worse with regard to foraminal stenosis, but in my case it seemed to help for some reason. Since the surgery, I have been slightly less tolerant to extension of my back, however it seems to be improving with PT. When I put my back into extension now, I don’t have any pain radiating down the leg, but do get a bit of lower back pain.

I will get in contact with my neurosurgeon and inquire regarding an oral steroid. I mentioned it at my last followup appointment, but he didn’t think it was necessary as I hadn’t been on my feet for long and appeared to be moving around quite well. Unfortunately here in Canada it can be tricky to get another MRI, but I’ll see what I can do if things don’t settle down in the coming weeks.

If I do have some height loss and foraminal stenosis at my L5-S1 level, is this something that typically requires additional surgery down the road, or can it be controlled for the rest of your life with activity, PT, etc?

Thanks again for your time.

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