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Dr. Corenman,
As discussed in the thread leading up to this e-mail, I’ve had 2 microdiscectomies on L5-S1 in the last 2 years to remove pressure on the right S1 nerve. Both times the surgery was successful addressing the right S1 nerve pain. However, I’ve developed the new right leg pain 2-3 weeks post-operatively along the L5 nerve believed to be caused by the collapsed disc (neural foramina narrowing). For the remained of this discussion, let’s assume this is true.
I am contemplating L5-S1 fusion and have some general questions which I plan to ask my perspective surgeon, but would like to get your opinion too.
I’ve read your post on “when to have the back surgery”. Unfortunately, it does not differentiate between less invasive (i.e. micro-d) and more invasive (i.e. fusion) surgeries. Maybe your position is that the surgery type is not relevant.
I’ve heard from so many people that fusion is a “salvage” procedure aimed in getting a completely disabled person back to “some kind of a life”. I am sure it started that way, but hope it does not still hold true. I am tired of living in nerve pain and back pain, but need to know how to effectively compare pros and cons of the fusion surgery.
How do I assess the probability of fusion helping vs. making the overall back or leg pain worse specific to my case? The question is not as easy as it sounds and I really struggle with it because I assume I will not reach a pain-free state even w/fusion. If that’s the wrong assumption, then I have my answer.
I have moderate to severe back pain with any level of activity including bending forward to pick anything up. But, have almost zero pain with rest, sitting or lying down. My job does not require me to pick anything up (desk job), so pain does not prevent me from working.
At rest, I have constant right buttock pain at rest (VAS 3) and intermittent thigh and calf parastesias along the L5 nerve. After an activity, the back pain is severe during any motion. The leg pain and parastesias intensifies and are divining me insane. However, it all goes back to baseline (rest) in 4-5 days.
So on one hand, I can function pretty well, but have to give up most recreational activities. On the other hand, I am miserable for being in constant pain and that I cannot play any activities.
Any suggestion you can provide, I would really appreciate. I want the fusion, but need to know the right questions to ask to make sure my decision is warranted. How do I get smarter on this?
So we will assume that there is foraminal collapse and L5 nerve compression due to the prior disc herniations.
The difference between a microdiscectomy and a fusion has to do with the anatomy of the region. First, if a new herniation has occurred (for a total of three), then strong consideration should be given to a fusion. The nerve root cannot become repeatedly compressed and still function normally. These compressions can lead to a “battered root syndrome” and chronic radiculopathy (see website).
If there is compression due to discal collapse (foraminal stenosis affecting the L5 root and not the S1 root), consideration can be given to a foraminotomy and not a fusion. The problem with a foraminotomy is that they are effective in the 70% range while a fusion is effective in the 90% range.
A foraminotomy will not help cure back pain which generally originates from a degenerative disc. For that, you need a fusion. A one level fusion at L5-S1 is consistent with competitive activity. It is not common for a one level lumbar fusion patient to have significant impairment.
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.Thank you for your response and keeping this forum active. I am very well familiar with the lumbar spine anatomy, fully understand my post micro-d CT scan and MRI reports, and doctors’ logic behind further treatment options.
I may have other surgical options for nerve pain, but I am only interested in fusion. I was reaching out to you for general fusion questions, not necessarily best treatment specific to my condition. I know exactly how on the paper the successful fusion will help. I know how it will “lift” the L5-S1 neural foramina to take roof-pressure off the nerve, decompress the axial nerve (if required), and stabilize the joint to relieve the axial back pain.
I have seen few doctors, but am struggling going forward w/fusion due to the inconsistencies on fundamentals which I think are important. My specific perspective surgeons disagree on the relevance of maintaining lumbar lordosis, need for direct vs. indirect foraminal nerve root decompression, relevance of neural foramina opening size etc. Also another dilemma, 1 or 2 levels.
Of course, some of this goes along with their fusion techniques (i.e. TLIF vs ALIF for direct vs. indirect nerve decompression, PLF vs. interbody for relevance of foraminal opening size). All surgeons have compelling arguments on why their plan of action and technique is the best my specific case.
Even published technical papers don’t agree on the “best technique” for the same clinical picture and patient symptoms scenario. I understand that the “tools” of the job can be different but don’t understand how fundaments can be different for something this important – an irreversible procedure.
Can you comment on this? My two failed micro-d surgeries left me very paranoid. In addition, the internet is filled with very bad fusion outcomes.
Fusion can be successfully be performed from anterior (ALIF-the belly approach), posterior, (a posterolateral fusion-PLF vs. a TLIF/PLIF approach) or both (a “360” fusion). All ways can be successful but there are some problems associated with each approach.
Restoring lordosis (creating a distraction of the disc space and tilting the L5 vertebra on S1) can be accomplished by the ALIF, the 360, the TILF and PLIF but not by a PLF. This also applies for distraction of the foramen.
Success rate for fusion is higher if you create a fusion bed both anterior and posterior and use instrumentation to create a more rigid construct. This only occurs with a TLIF, PLIF and 360. You cannot perform a posterior fusion with an ALIF and by definition, you don’t have an anterior fusion with a PLF.
The anterior fusion (ALIF and 360) has some problems that can occur. This is abdominal wall weakness, potential great vessel injury, retrograde ejaculation (in a male) and adhesions of the small and great bowel. This is why I only use this approach in unusual cases.
Posterior “360” fusions (PLIF and TLIF) have some potential problems including nerve retraction and resultant irritation. The PLIF involves more root retraction and is bilateral (vs. unilateral in the case of a TLIF) so has a higher possibility of root irritation.
This brings us to the TLIF. It has a very high rate of fusion, there is less root retraction and with good technique, lordosis can be restored. Bone graft comes from the vertebra itself so no additional graft has to be used. This is why TLIF is my primary technique for a segmental collapse.
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.Dr. Corenman,
Thank you for actively supporting this forum. I have learned a ton reading peoples questions and specifically your answers.
I am a 36 year old healthy male, 6’3”, 210lbs. I had my 1st L5-S1 micro-d in 5/2012 and 2nd (due to moderate reherniation) on 5/2013, both to take pressure off the right S1 nerve root. Both surgeries alleviated the right-leg nerve pain along the S1 greatly; however within 2 weeks of the 2nd surgery, I believe I have reherniated for the 3rd time, except this time it’s into the right formanial area where the L5 nerve root is sitting based on the leg symptoms I describe below.
CURRENT SYMPTOMS
The back pain is present 100% of the time and varies in intensity depending on the activity. It is located just to the left and to the right of the lumbar midline and wraps around both hips, all the way to the top of the iliac crest. If I am not moving (i.e. just standing or sitting), the back pain is 0 VAS. If I had a moderate workout the back pain can be as high as 8 VAS where I cannot even bent slightly at the waist. In addition, I have constant bilateral buttock pain which also varies in intensity. At all times, flexion hurts more than extension. I do not have any instability as presented on the recent flexion/extension standing x-rays. I take no medication.
My right leg pain in along the right L5 nerve dermatome (pain on the outside of my calf, top of my foot, and big toe). I can dial it at depending on my torso positioning or movement. If I am stending up straight and lean to my right while standing (as in closing the foraminal gap) the pain jumps to 8 VAS and my right forefoot and big toe starts tingling. As soon as I back off the pressure on the nerve (torso back in neutral), the pain goes to 1-2 VAS. It’s like an on/off switch. Activity and stretching improve the overall leg pain. It almost diminishes after Yoga for example for few hours and the on/off switch is more difficult to reproduce.RECENT MRI READING
At L4-L5, there is a symmetrical disc bulge with focal left foraminal protrusion which flattens the ventral thecal sac and moderately narrows the left neuroforamen and impinges the left L4 nerve root.
At L5-S1, postsurgical changes of right L5 and S1 laminectomies and again noted which decompresses the central canal. There is broad-based disc bulge with right-sided inferiorly oriented disc extrusion by approximately 4 mm. This results in severe narrowing of the right lateral recess. Additionally, there is enhancement in the right foraminal zone and in the soft tissues of the laminectomy sites, likely secondary to the granulation tissue, slightly decreased compared to prior MRI. This results in severe narrowing of the bilateral neuroforamina with impingement of the right L5 exiting nerve and a second right S1 nerve root. There is also an impingement of the left L5 exiting nerve.RECENT DISCOGRAM READING
L4-L5: 3 mL of contrast was injected with soft endpoint. The patient did not pain during the procedure. Contrast extends diffusely throughout the disc indicative of the generalized degenerative disc pattern. Schmorl’s node formation is noted in the superior and inferior endplates. There is contrast noted diffusely throughout the disc and extending into the Schmorl’s nodes. There is minimal generalized bulging of the disc without contrast extension through the posterior annulus. The facets are normal. There is no significant narrowing of the central canal. There is minimal narrowing of the neural foramina bilaterally secondary to the generalized disc bulging.
L5-S1: 3mL of contrast was injected with a moderate endpoint. The patient reports 6/10 discordant pain in the back. The contrast pattern demonstrates diffuse degenerative disc change. There is contrast noted diffusely throughout the disc indicative of generalized degenerative disc disease. There is also generalized bulging of the disc as well as cephald extension of contrast presumably within the area of the disc extrusion into the right foraminal region abutting the exiting L5 nerve root. There is also cortical extrusion of contrast presumably in the area of extruded disc in the posterior central location just touching the anterior aspect of the thecal sac.
The facets are normal.The interesting thing about the discogram is while I was laying there feeling the pressure, the pain was 6/10 as it states above and it was discordant. However, within 20 minutes of me getting up, I felt the same concordant pain. It was delayed by 20 minutes. The next two days, the same concordant pain persisted, just like after a major activity like a long hike or a game of basketball. Any explanation to this?
Painwise, I can do all things I need to do. I cannot do many of the things I’d like to do in my current state. The back pain is more debilitating, but the right leg pain is more bothersome. Does it make sense to proceed with the one-level lumbar fusion and why? I am extremely nervous and cautions about jumping into a salvage procedure. How do I build an objective case of pros vs. cons? In my mind few things do not form a clear case:
1. Discordant pain
2. Two previous micro-d procedures (I am thinking scar tissue)
3. No relief after 2 epidural injections around the L5 nerve root
4. Normal Sensory / EMG studyHow straight-forward is my case based on my symptoms vs. films and chance of improvement with fusion?
Any comments on the meaning of the reports above would be appreciated. Your staff said that you are not doing video consultations any longer.
Great questions-you have done your homework! The EMG study is not expected to have any changes as this is a dynamic condition (see EMG on this website). The “dynamic condition” means that the nerve root is only compressed under certain conditions (standing or certain sitting positions) and “you can get off of the nerve” by adopting other positions. The nerve would probably not be noted to be injured on an EMG.
Back pain is most likely from the L5-S1 disc. You have had two prior operations and this disc probably represents IDR (isolated disc resorption-see website). Some of you other complaints could also be from the bone injury of the endplates with IDR (“I have constant bilateral buttock pain which also varies in intensity. At all times, flexion hurts more than extension”).
I would also not expect instability with IDR at L5-S1 but it is good to know that L4-5 has no instability. (“I do not have any instability as presented on the recent flexion/extension standing x-rays”). I will assume that L3-4 is a normal disc on MRI.
Your description of the L5 nerve pain from foraminal stenosis is classic (” My right leg pain in along the right L5 nerve dermatome (pain on the outside of my calf, top of my foot, and big toe). I can dial it at depending on my torso positioning or movement. If I am stending up straight and lean to my right while standing (as in closing the foraminal gap) the pain jumps to 8 VAS and my right forefoot and big toe starts tingling. As soon as I back off the pressure on the nerve (torso back in neutral), the pain goes to 1-2 VAS. It’s like an on/off switch”). This should be important reading for any medical student as it is a perfect description.
I am not worried about the discordant findings on your discogram at L5-S1. It should be noted that discograms are rated P0, P1 and P2 for the potential pain generation that can occur. P0 is no pain, P1 is discordant pain (pain that is present with pressurization of the disc but it is pain you don’t recognize) and P2 is concordant pain (“That’s my pain!).
The fact that you have had no pain at L4-5 with the discogram but the injected contrast noted a degenerative disc raises a question that cannot be easily answered. It seems that you are a good candidate for a fusion at L5-S1. This surgery has a high chance of removing at least 2/3 of your lower back pain and your leg pain. The question is what to do about L4-5.
This level is not now causing pain. What are the chances it will cause pain in the future? After all, the level at L5-S1 now does not move much now if at all. Fusing this level will not change your current biomechanics. So the question is: what will happen to L4-5 if left alone? This is the real question.
There was a study some years ago that said the level above has a 2.5% chance of needing surgery for every year after the L5-S1 fusion. I think it might be higher at about 3%/year. This means that in 10 years, you would have a 30% chance of needing further surgery. It might even be higher if you participate in impact sports (tennis, running, football) or weight lifting where squats or cleans are used.
The question is then should you consider a fusion also at L4-5 also? Personally, I would tend to leave this level alone but I have many patients to don’t want to consider further future surgery and want to have both levels fused at once. I fully understand that and their answer might be correct. I just can’t predict what will happen to this level above.
The last question is what to do with “No relief after 2 epidural injections around the L5 nerve root”? The main question is were you asked to keep a pain diary for the first three hours (see pain diary on the website). Most injectionists do not ask you to aggregate the leg pain prior to the injection and then do not ask you to test for pain relief in the first two-three hours. Long term pain relief is worthless for diagnosis and I will assume you were not asked the specific questions noted above.
This was a long answer but you need to know all the factors before you make a decision.
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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