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  • nakurac
    Participant
    Post count: 8

    Dr. Corenman,

    Thank you for actively supporting this forum. It speaks volumes about desire to help educate the patients.

    I am a very active 34 year old male, 6’3″, 207LB. In May 2012, I have had the L5-S1 microdiscectomy to alleviate the pressure on the right S1 nerve that was causing the dull aching/burning right posterior and lateral calf pain that was persisting for 6+ months. Three months after the surgery, I returned to soccer and basketball and was overall happy with the surgical results. I did notice that my lower back pain was somewhat worse at all times.

    In March 2013, I reherniated the same L5-S1 disc (central/right again but herniation is significantly larger) compressing the same S1 nerve, and had a slightly different type of radiculopathy. My lower right leg was feeling pins and needles and slightly asleep. No weakness. Although this has 75% resolved by rest and pain meds (which I take no more), my lower back is significantly worse than it has ever been. I am still playing sports 1 x week, however.

    Can lower back pain be due to the “moderate” disc herniation and would another microdiscectomy resolve (at least partly) the lower back symptoms in addition to the remaining 25% of leg pain? I understand the microdiscectomy is the “gold standard” for resolving nerve pain due to impingement, but somewhat controversial for resolving the lower back pain. I guess the question is, can my new ACUTE low back pain be due to the herniation? I have 2 level DDD, L4-L5-S1 and I know that’s the cause of the dull back pain I have always had even before my 1st surgery in 2012.

    It’s worth saying that L4-L5 is not herniated and is unchanged in the last 2 years. Classified as “mild” DDD on the MRI’s.

    If I knew I will get no lower back benefit from microdiscectomy, I would not schedule it. My neurosurgeon is not sure and is letting me decide on the next steps, but is leaning more toward the 2-level fusion. However, he would support my decision to go with micro-d as he believes it MAY help the back pain too.

    I would not do the fusion if I knew micro-d would help and not cause nerve damage / impingement due to further scar tissue. I am very worried about further risk to the nerve with micro-d, but extremely scared of the fusion especially after I don’t know if I need it (yet).

    Any help you can provide, I would really appreciate.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    Back pain is generally caused by degenerative discs and facets, not by disc herniations. The most likely reason you had increased pain in your back after these two herniations is that the shock absorbing “cushion” of the disc (the nucleus) displaced into the canal. This reduces the impact absorption of the disc. The disc now has less stability just like flattening a car tire and then driving the car. The tire won’t “hold the road” well.

    There are occasions that disc herniations can contribute to some of the lower back pain complaints. The herniation can “tent” the posterior annulus (see anatomy of the lower back for full description of annulus). This annulus contains pain fibers that contribute to lower back pain. Sometimes, removing the herniation can reduce lower back pain. I tell all patients that are undergoing a microdisectomy to relieve only lower back pain to expect a 50% success rate for satisfaction.

    The reason some patients elect to undergo this microdisectomy with a 50% satisfaction rate is that the other potential surgical procedure for relief of lower back pain is fusion. Fusion of course is a procedure that has a longer recovery time than a microdiscectomy and is a more extensive procedure. Failure of the microdiscetomy to relieve lower back pain does not preclude a potential fusion surgery in the future.

    Do you need a fusion? No one can answer that question but you. You have to look how this pain affects your life, thoughts and occupation. See the section “When to have lower back surgery” for further understanding of this issue.

    Dr. Corenman

    nakurac
    Participant
    Post count: 8

    Thank you for your reply. After consulting with 4 spine surgeons, I have decided to proceed with the repeat microdiscectomy.

    What’s your possition on micodiscectomies done with tubular retractors? I read a lot of articles that conclude that patients experience more post-op back and leg pain after microdiscectomies done with tubular retractors than after conventional microdiscectomies. The articles don’t explain why. They are both considered minimaly invasive and are aimed to achieve the same result. Doctors that use them love them and the doctors that don’t are against them when I talked to them. Both only provide one-sided stories.

    Thank you in advance.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    A tubular retractor is simply a retractor like any other device that holds tissue (muscle and fascia) out of the way while surgery is being performed. I find these tubular retractors useful in the lumbar spine only for far lateral herniations as they limit the field of view and constrain the tools that can be used for the freeing of the disc fragment.

    Nonetheless, just because I do not use them for typical posterolateral disc herniations does not mean they are useless. These retractors do limit the field of view but in most cases do get the job done. I have two surgical videos that will give you an impression of what these two retractors look like in real time. The first, using the Taylor retractor is the lumbar microdisc video and the second is the posterior cervical foraminotomy/microdiscetomy using the Metrx tube retractor.

    In reality, if some surgeon is comfortable with any retractor system, the surgery should be a success.

    Dr. Corenman

    nakurac
    Participant
    Post count: 8

    I had a repeat microdiscectomy in late May to remove material pressing on the s1 nerve. Surgery went without complications, but 2 weeks after a moderate sharp leg pain returned. 4 weeks after surgery date (two days ago), the pain became severe and in locations other than where a dermatatome map shows for s1 pathology. Yesterday’s MRI report indicates a severe right foraminal stenosis secondary to the granulation tissue at l5-s1.

    I am worried about this finding and feel hopeless. Looks like I traded one problem for another much more painful and serious. What should I do? Could this be the temporary result due to tissue inflammation? I am still awaiting my surgeons advice.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    New and different symptoms that do not mimic the prior S1 root but seem to be “in locations other than where a dermatome map shows for s1 pathology” is more likely than not, an L5 nerve problem.

    However, a repeat microdiscectomy at L5-S1 should not cause L5-S1 foraminal stenosis as this foramen is above the disc space by about 12-15mm and really does not become involved with a standard discectomy.

    The new MRI notes “severe right foraminal stenosis secondary to the granulation tissue at l5-s1”. I am puzzled about the cause of this granulation tissue. You could have an infection which would produce granulation tissue that migrates up somewhat so hopefully that potential diagnosis is on the table. This could be a hematoma (a collection of blood products) which should be obvious on an MRI.

    I imagine it is possible that this is just exuberant granulation tissue that has migrated quite a distance but I have to say that it would be unusual to have the L5 nerve involved and not the S1 nerve.

    One thought is that the disc re-herniation caused the collapse of the disc space and compression of the L5 nerve. See foraminal stenosis on the website to understand this disorder. Foraminal stenosis pain would typically be standing and walking leg pain that reduces with sitting.

    If there is no infection present, then I would consider a selective nerve root block at that level.

    Dr. Corenman

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