Tagged: Antalgic (pain-driven) scoliosis
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Thank you everyone for this discussion. This is one of the core questions in spine, when to have surgery for a herniated disc without motor weakness. There is no right or wrong answer. It is really a question of pain toleration and if the pain will fade over time without surgery.
If the pain is severe, most patients will opt for surgery but I do try epidurals on the ones with moderate pain (and no motor weakness) for the chance that a great result will occur.
The question is what will happen to the patients with moderate pain that don’t improve with injections and physical therapy? There is a general impression in the spine community that after three months of pain and activity restriction without much improvement, surgery should be strongly considered. There are some studies that indicate patients with nerve pain after six months do not do as well with surgery as those who have surgery before six months, possibly due to chronic nerve injury.
Add antalgic list (painful tilting) and the suggestion for surgery becomes stronger. I have seen patients with an antalgic list improve without surgery, but the time to improvement and the resolution of the list takes much more time with a lower percentage of successful resolution.
I agree with Princess that this painful tilt can also cause other loading problems with knees and hips. If there is a preexisting but non-symptomatic problem (arthritis or ligament deficient knee), the list or tilt can aggravate the symptoms.
I also think that the microdisc surgery is quite remarkable for this particular condition. The incision is very small and the results are very good. The nerve is immediately decompressed and the success rate (would you do the surgery again if you were in the same situation?) is almost always yes. Nonetheless, I do not push the surgery on patients as every patient is different and there is sometimes fear of surgery which is understandable.
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.Wasn’t able to write sooner because of some things that had to be done.
Well, what I learned from my experience is that in these situations you should really really try to avoid the “what if” way of thinking. Because, if you think about it, it does not help you no matter the outcome.
Yes, i saw improvement on the 6 month mark. But it was like: improvement, feeling better, plateaux, feeling bad, improvement, feeling better, plateaux, feeling bad and so on. In one of those plateaus, i had almost arranged the surgery but I cancelled because another improvement stage happened in the meanwhile. So, after a while, when you realize how it works, you have to persuade yourself to detach your feelings from the immediate results and try to focus on the long term outcome. If you are getting better, even in a slow pace, then you are getting better long term.
So, please, do not ask yourself if it would be better to do your exercises earlier or not. Or what would have happened if you had done things in a different way. You know why? Because the answer can’t be known. Remember: there is a chance that the exercises would be helpful, but, there is ALSO a chance that the same exercises would make the surgery more difficult, there is even a smaller chance that it would make the whole situation much much worst. Eg, in my case, my antalgia was the result of exercises which i did with the help of a physical therapist. There is no doubt about that because we were doing the exercises under the effect of voltaren and the moment i stopped the injections the body responded immediately with antalgia (within less than 6-8h, after end of exercises and sleep).Do you know what exercises we did? We did exercises to straighten the spine because the x-ray revealed a minimal scoliosis. So, the therapist believed that this caused the herniation and not the other way around. So he tried to “fix it”, in order “to decompress” the disk. You see? Those would be the same exercises i would have to do if the herniation was gone and my problem was the scoliosis itself.
So, you should perceive both choices: surgery or not, as equal. Both with risks, advantages and disadvantages. But once you have made a decision, its time to focus on the future. One way or another, you did decide to proceed with surgery. All the information you had (both from your body and from the doctors) lead you to this logical decision. So, it was a proper decision. You also have a baby which is a very important thing to consider. If i had a baby, i wouldn’t be able to wait that long for sure.
In my humble opinion, odds are strongly favoring you. They did remove the herniation, you do feel better and you did see a significant change, so you have every reason to believe that your spine will realign. But you have to give it time because, as you said, by removing the herniation at once, the body does not have enough time to adapt to the new signals sent to the brain.
If your herniation was the result of an accident, then i wouldn’t have any other advice to give to you other than to have patience. If your herniation was the result of life style, then, as a patient -and not a doctor-, i would say to you that even if the herniation is gone, its better to avoid sitting a lot before your spine realigns completely. And generally read the basics about the spine (there is a lot of info on the net these days), and avoid doing all those things that harm it until it realigns. Maybe Dr. Corenman can tell us what the doctors would say in this situation. Till your spine aligns though, stay positive, you really have every reason to be positive.
So, regarding the questions you ask me:
1) About specific exercises … I didn’t do any specific exercises to realign my spine, apart from walking. Initially small distances at slow pace, and increasing the distance day by day. But i did change my life style. When i injured my spine, i was working a desk job, sitting 8h-10h, 5 days per week. Now, i’m a teacher, so i can sit, stand, walk and switch, during teaching. This helped a LOT. If your injury is the result of your life style, then imho you should consider changing it since the body sent you a huge message that it hurts. Don’t focus on antalgia itself. Imho it will go away. Focus on the real problem so that long term you don’t end up on the same spot.
2) About my life at the time… wow that’s a tough question.
My life at the time of the intense antalgia was HELL. I mean, i couldn’t do anything. I stopped basketball and football which i enjoyed playing a lot. I couldn’t sit, I couldn’t run, I couldn’t walk. I couldn’t take a long bath. I felt terrible. I did blame myself at the time for the various mistakes i did that lead me to this situation. But, first you have to win the mind game, and then the physical one.
Did I expect to improve? yes. I did expect to improve. My fear was not whether i would improve or not. My fear was, and is, whether i will eventually be able to return to contact sports at 100%. Also, my fear was whether I will have to undergo spine surgery again and again till my 80s etc. Those were my fears.
There are many reasons why i decided to avoid surgery and was positive (as much as i could at least) during this period. I am not going to write all of them, i need a lot of space for that but, i will tell you one:
I saw more than 5 doctors. One of them told me that i should replace my disks with implants, the other one that i should do nothing but wait, the other one that i should choose microdiskectomy because it is the most tested technique and the other one that i should try discogel. The problem is that each doctor offered as a solution what he knows better to do. It didn’t make sense to me. So I searched the net a lot, and read a lot about spine. A LOT. I read publications about spine surgery, mckenzie books etc. I did that so that i could choose correctly which doctor to trust.
At the same period i posted my problem to a forum of my country, and asked for people who had the same problem to communicate with me. I still remember three people (but i have talked to more). The reason i did that was because i needed experience from the patients and not from the doctors:
The first one was a man at his early 50s, who had the same problem i had at his 30s. Huge herniation and antalgia. He wasn’t able to walk for about 1year or sth. He did reject surgery. And guess what? he was a wind surfer and he was able to wind surf at his 50s!!! So, he told me that the pain will go away, and that only a few people need to undergo surgery later on. He told me to not rush surgery, because surgery is always available. And that sometimes 3 or 4 years may pass before your return to normal life. Of course, if you have a family that’s a whole different story. But if you don’t have a family and can wait, then this period can be a training period to learn how to protect your spine.
That was very helpful to me, because from the net i had concluded that most people with back pain would have back pain for ever. But he didn’t follow that pattern. He had back pain for about 3-4 years, and then he had no back pain till his 50s (not even his 50s). That’s almost 15-20 years no pain.
The other one was a young kickboxer, around 28. He had the same problem, antalgia because of a huge central herniation because of an injury in kickboxing. Guess what? he also had pain for 1y, but at 1y 1/2 he returned to kickboxing. At the moment we talked he was back in training but he decided to stop kick boxing competitively. He also told me that it is a nightmare and that you will have to be patient.
The third one, was a lady at her 40s 50s i am not sure. Again the same thing. Herniation at her middle 30s, antalgia etc. She chose surgery *immediately*, within 1 week or so. Her surgery had complications (spine fluid loss or sth? i dont know how it is called in english). Despite that, more than 10 years had passed without pain AT ALL. She was a success story of microdiskectomy.
So you see, these people helped me understand that both choices (waiting or microdiskectomy – i immediately excluded fusion from the list) could lead to a painless life and that things are not as bad as they seem. So i decided to wait, mostly because i didn’t find a proper doctor to trust.
If all the doctors had given me the same advice, perhaps i would have had chosen to proceed with the surgery but the fact that each one was suggesting a different method caused distrust to me.
So, stay positive. Most probably your spine will realign, and if it does not completely realign, there are plenty of exercises you can do to strengthen your body and live a normal life.
First-thank you for your heartfelt discussion of your spine journey. Your history and subsequent discussion will be helpful for individuals in your circumstance.
I do want to make a point as I don’t want to create confusion regarding different disorders of the spine. There is a significant difference between the patients who have herniated discs causing leg pain by nerve root compression and patients with lower back pain. These are two different disorders. Lower back pain is an intrinsic disorder of the disc, vertebral body and/or facets that is generated by overload of the disc or instability of the vertebral segments. This is a very different disorder and should be separated from radiculopathy (compression of a nerve root by disc herniation).
I also want to separate out disc herniations producing pain and numbness vs. herniations that cause motor weakness along with the other symptoms. Motor weakness is a much more serious problem and in my opinion needs to be addressed surgically. Surgery affords the best chance of recovery of good useful motor strength.
The patients that should be concerned with this discussion are the patients with a disc herniation and a painful leg without motor weakness. It turns out that 90% of HNP patients fit into this category so this is the most common presentation.
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.Hi,
This discussion has been most stimulating and I am sure it will help other sufferers who are looking for information relating to antalgic scoliosis and heeniated discs. I would like to thank Dr Corenman for his insights and opinons and the person who opened this thread.
I agree with Dr Corenman that if motor weakness appears then surgery should be considered. I was afraid that I may cause myself significant nerve damage if I did not have surgery. The two surgeons I saw were very experienced and had an excellent track record, so when I asked them they both looked at me, my MRI, and the time I had already been suffering. I think I just wanted something to resolve my problem. I was terribly depressed. My whole life had shrivelled away, and I just didn’t like the idea of waiting it out. I had already waited for nearly a year and I did not see an improvement so I was not convinced I would improve. What if I did not? I had a child and I was unable to stay unemployed and put my life on hold. The banks, the sympathizer’s and eveyone else are hardly patient. People want you on your feet. No one cares or is sympathetic about your problems. I just couldn’t see how I could live a stress free life while waiting to recover because the timeframe I was givem by all the professionals was 2-5 years. By that point my body would have become crippled. I already had some other health problems with my knees. I even started to put on weight because I was unable to walk or do much else, and as the pounds piled on, I knew it was only a matter of time before my problem got worse. I admire the OP for his fortitude and positive attitude. Your belief in your body’s healing power is remarkable and I am happy that your outcome was a good one. Both our stories may help other people make their choice.
I have one final question for Dr Corenman. I had the surgery and my physio and surgeon have said that even if it takes several more months my body will realign. After it does, the achea and pains I have at present will subside. Once the process is complete, my fear would be reherniation. I was told the possibility of the disc reherniating are quite slim as long as one is sensible and does not do anything that unduly causes stress to the spine. Howevee, it seems to me, being in my mid-30s, that I have a long time to live and with half of l4/l5 gone, this problem will rear its head again. Even with precations wouldn’t the body just wear down#? If reherniation is rare, why is this? Is the disc much stronger than we think? Even after surgery, does it still have enough strength to keep going? Most of the doctors and physios I have seen say that a person who has disc surgery, even if they are ratively young, they will ot necessarily have disc related problems if they keep thwor back strong and do not do anything that is known to cause damage to the discs (slouching, bending, lifting something heavy, etc). They also told me that a reherniation would be the result of wear and tear or one very traumatic event but I often fear day to day movements because I wonder how they will cause stress to my back. The last thing I want is the antalgia to return because it is so hard to straighten out after it, especially if you already have other health problems thac may cause a potential setback.
In thw UK you can either go to the hospital in an emergency (where they may operate on you if they consider your condition bad enough), or you have to wait to see a consultant. Health care is free but there is a downside. Everyone uses the health service and waitinf lists to see consultants can be long (and tests cans add more time – they are rarely done on the day). If you are deemed fit for surgery often there is a waiting list for that too, and in my case it took several months from the point I first saw a doctor to the point I had surgery.
This means if I ever have this problem again I will have to wait a long time for diagnosis ans treatment and I just want to avoid a reherniation. Anyway sorry for an unfocussed post. I hope those that have already been here and those that will see this thread in the future are freed of their pain and disability one way or the other. Please be strong and have faith that if nature cannot restore your function, doctors can do a grand job of restoring your health. Dr Corenman here has provided some terrific information about disc herniations and the different types of problems they can cause. I hope these forums also help sufferers and enhance their understanding of particular problems such as antalgic scoliosis.
I hope to post again when I see further improvements, but if I do not I hope my story has helped extend this discussion in a useful way. For now, bye bye everyone.In my experience, the chance of a recurrent herniation is about 10% across the board in an active population. You cannot fear that recurrence. Although the odds are different of course, this would be like fearing getting hit by a meteor when you walk outside. Could it happen-yes. Will it happen-unlikely.
Discs are resilient. You can have a tear of the annulus or a disc herniation and a microdisectomy and never have another problem with your back. You do need to stay strong in the core and avoid heavy lifting.
I can’t tell you how many countless patients have unbelievably miserable looking backs and have no symptoms. Don’t focus on what might happen but go out and live your life. Yes, you might again have to visit national health care with all of it’s pitfalls.
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.Hi. I was sitting in a chair twisting to the left about 5 months ago, kinda feeling a stretch in my thoracic spine and suddenly got a quick intense sharp pain right where my lower back goes into the si joint/glute medius area and within seconds of feeling this quick, but very intense, pain, I felt my body twist out of position to where it was like I was looking to the left and twisted that way internally regardless of what I did. If I relaxed my body with feet straight, my upper torso would fall to the left, where as the front of my stomach would be at an angle to the left. I’ve been to 3 chiropractors, my current one very good, and the problem has gotten better, to where I don’t feel near the pressure in my right lower back/hips when I put my feet straight and try to stand forward, but I still feel twisted internally and the muscles of the thigh and glutes are constantly developing tight ropy trigger points that I work on with aggressive deep tissue work and even had my chiropractor dry needle a few of the spots. It feels like I either injured my glute medius or did something to a disc that is causing my body to stay twisted. If I stand at the bottom of stairs and get my feet squared up in the middle, and then look up the staircase, it’ll look like there’s more left field of view than right, and it feels like I’m closer to the right wall than left, even though my feet are squared up center. When I walk in a straight line, it’s like I’m twisted more to the left, I can never get truly squared up to what’s in front of me, and the dynamics of my upper back structure feels twisted. I get a dull ache on the right side when I sit too long, but I can run and walk endlessly with no pain, and it feels like twisting to the left is a bad idea. My glute has atrophied significantly. My right foot wants to pronate out all the time, although it’s gotten better with work on the trigger points that come up, it’s still wants to drop forward and pointed out from the other foot. X ray shows a slightly rotated pelvis with the eye holes at different sizes. Do these symptoms sound possible from a twisting disc injury? At this point I just want my body to be straight again so I can get back to real exercising and movement without feeling internally twisted and like I could easily injure myself from making a wrong move. Thanks for any answers or similar experiences.
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