[BD Jackson]

#9340

I would be grateful for your thoughts on what is causing me leg and back pain. I had a microdiscectomy operation in March of this year, this followed a short bout of sciatica which lasted until I tripped down a steep curb in February and herniated the disc in my back,l4/l5. During the days following the trip i had pins and needles in my leg and eventually started having difficulty moving my foot. I went to see my GP who referred me to the A&E department which diagnosed foot drop, this was not total foot drop however. Within a week I was given an MRI and within 2 weeks I saw the consultant who diagnosed a massive herniation. By this stage i did not have any leg and back pain whatsoever. He told me that the nerves in my leg were being severely impinged and he put me on his urgent list and I was operated on 4 weeks later.Just 5 mins prior to the operation he confirmed whether i had problems with my bowels as he had expected cauda equina syndrome, but luckily i was ok.

The recovery went pretty well I only took 2 lots of paracetamol for a couple of days after the op and felt that i didn’t need any more despite the fact that there was some pain at the wound site and pain in my hip/buttock area, which initially made it difficult to sleep. I also had numbness on the top left handside of my foot and down the calf.

By mid May I was feeling pretty well, no pains, walking at least 6 miles a day and doing the exercised prescribed by the hospital,however i wasn’t yet driving. So when i went to see my GP about returning to work she suggested that i should try driving, which i did, and found i didn’t have any problems with it. I also asked my GP about physio to strengthen my core and foot. At this stage in my recovery there were a few times when I would get leg/back ache after standing for a long while in the same spot and would have to lie down to relieve it.

I returned to my job at the beginning of June, this was a phased return and ended up being over an 8 week period. During the 2nd week at work i started to develop low back ache on the left hand side and pain in my buttock/hip area which travelled down the leg and gave me a vague tingly feeling in my foot. My job involves spending a lot of time sitting at a computer. I went back to see my GP about the pain and she said that she wasn’t sure if this was something that could be expected to happen and saw it as a retrograde step and said i should make an appointment to see the consultant, the appointment was for 6 weeks time. In the meantime over a period of about 2-3 weeks the symptoms went away and i finally felt i was getting somewhere. However I went on holiday at the beginning of August for 1 week, I did do some driving and i also did some exercises, not as many as i had been doing. On my return from holidy i felt fine, however on my return to work i started having the lower back pain and pain in hip/buttock which radiates down the leg and in to the foot. This has been going on for 3 weeks now and is much more painful than when i first returned to work. When i am at work i take a break every 30 mins and have a walk around and go for a walk around the block.

When I wake up in the morning my back and hip/buttock area are fine, however as the day goes on the pain becomes progressively worse until i am at the stage where i can neither sit or stand. The pain is in the lower back and hip/buttock area, and can feel tension down my leg all the way to my foot. The only relief I can get is lying down on my side, and actually lying on the side that is pinful.Whilst i have been having this episode i have been contining with the walking, but this is probably only 3 miles per day, and with the exercises, i finally managed to start seeing a physio 3 weeks after i started back at work.

I would be grateful for your advice on what may be the cause of the pain and what if anything i can do about it,

Many thanks

[Donald Corenman, MD, DC]

#9342

You had a typical post-operative course from your microdiscectomy but with a slower advised increase in day-to-day activities. Most of my patients are back to full activity by six weeks except athletes which are back to full activity by eight to twelve weeks.

Return of significant buttocks/leg pain and paresthesias (pins and needles) after a relatively good symptom recovery can typically mean one of three things; chronic radiculopathy, recurrent herniation or vertebral instability causing mechanical compression of the root.

Chronic radiculopathy (see website) is caused by the initial damage the nerve suffered by the herniation. Removing the compression is the surgeon’s job but mother nature has to allow the nerve to heal. This healing occurs 95% of the time. If the nerve is not significantly damaged but easily irritable, activity modification, medications and epidural injections can be very helpful. Very rarely, further treatment can be necessary (spinal stimulation-see website).

Recurrent herniation occurs in about 10% of the active population. This is generally unavoidable. If you have a recurrent herniation, you should have increased and more intense symptoms and your examination change should be apparent to your surgeon. The way to diagnose this is with a new MRI with contrast (gadolinium).

Mechanical compression can occur from the loss of the jelly in the jelly filled donut (nucleus). Think of the jelly as the air in a tire. If you let air out, the tire collapses and the side walls bulge. This bulge can compress the nerve or the instability of the vertebra (think of driving on a flat tire) can cause shifting of the vertebra and compression of the root. This condition is diagnosed by a very thorough history and physical examination. X-rays with motion are also helpful to diagnose.

Possibly one trick can help with this flair-up. A short course of oral steroid can reduce inflammation and reduce pain.

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.

[Dan John]

#9890

Dear Dr. Corenman,

I was involved in different sports which required heavy lifting since i was 13.I am 28 now and my spine is very damaged.
I had a discectomy surgery back in February at L4-L5 and L5-1, after sigificant back and leg pain for more than 4 months.I couldn’t walk on my left heel and my left toe had no strength and coudn’t bend to tie my shoes.

Unfortunately i have a recurrent herniation at both levels.In the MRI report it says:
– left foraminotomy with minimal protrusions at L4-L5 associated with osteophytes which are in contact and fibrotic modifications in with L5 roots bilaterally the 1/2 part of thecal sac post surgery.
– left hemilaminectomy with fibrotic modifications in left 1/2 part of the spinal canal with the “encapsulation” of S1 root into canal/(intracanalicular?)
– median and paramedian minimal discal protrusion on the left at L5, apparently not compressive
– dehydration of L4 and L5 discs
– posterior discal protrusion of T11-T12 with small compression of thecal sal without associated radiculopathy/nerve compression
– minimal/small intraspongious hernia of L2
– small spaces between T7-T11 verebrae associated with small intraspongious hernia
– round thoracic kyphosis
– diminishing of the normal cervical and lumbar lordosis
– small thoracic-lumbar scoliosis
– dehydratation of C4-C5 and C5-C6 in the initial phase
– small discal protrusion at C5 without compressing the nerve
– small posterior lateral left disc osteophyte herniation at C3 and C4 neuroforaminal narrowing, apparently not compressive
– vertebrae osteochondritis of thorachic-lumbar spine

There are a few more problems.

I feel a burning sensation in my left leg and some “pins and needles” occasionally.

I have similar symptoms like the one who started this topic:

“When I wake up in the morning my back and hip/buttock area are fine, however as the day goes on the pain becomes progressively worse until i am at the stage where i can neither sit or stand. The pain is in the lower back and hip/buttock area, and can feel tension down my leg all the way to my foot. The only relief I can get is lying down on my side, and actually lying on the side that is painful.Whilst i have been having this episode i have been contining with the walking, but this is probably only 3 miles per day, and with the exercises, i finally managed to start seeing a physio 3 weeks after i started back at work.”

The lower back pain is a 4-5/10 right now but has increased in the last month and the leg is not hurting but is annoying to feel the ocassionally leg burning/pins and needles(paresthesias).

Last time i have done decompression machine, chiropractic care, AINS, dexamethasone/xilin shot, all without effect.when i had the injection my pain was down and i could sleep but after the efficiency i had a drop foot.
For the moment i am not going to the gym and i am doing daily stability for the core muscles.I really hope that it will be better but it’s getting worse.

What do you suggest to do or what do you think is the best solution in my case right now?
It is neccesary to think at a fusion although i am scared to do this thing regarding my age and the stifness and incapacity that comes with it or a microdiscectomy although the chances to reherniate them a 3d time are bigger?
I have any other chance instead of surgery for the nerve symptoms to go away?Do you know people that the nerv symptoms subside without surgery?
Do you know if it is possible the compression to subside?

I really appreciate if you can help me with an advice based on your experience.

Thank you,

Dan

[Donald Corenman, MD, DC]

#9893

I am unclear now as to your current status for motor weakness in your left foot. You had prior foot drop (weakness of the tibialis anterior muscle) and underwent surgery. Did the foot drop fully recover? Do you now again have recurrent foot drop or did the preexisting weakness increase recently?

The radiologist does not make a point of stating there are recurrent herniations. He states there are bone spurs and adhesions where the old surgery took place “left foraminotomy with minimal protrusions at L4-L5 associated with osteophytes which are in contact and fibrotic modifications in with L5 roots bilaterally the 1/2 part of thecal sac post surgery”. I cannot tell if he is talking about the lateral recess (see website) where the L5 root resides or the foramen at L4-5 where the L4 root exits the spine. He does discuss the L5 root so I assume this is the lateral recess where this spur/adhesion complex exists.

He then discuss what I believe to be the L5-S1 level but he does not identify the level discussed based upon this dictation “left hemilaminectomy with fibrotic modifications in left 1/2 part of the spinal canal with the “encapsulation” of S1 root into canal/(intracanalicular?)
– median and paramedic minimal discal protrusion on the left at L5, apparently not compressive. This last sentence he indicates that there is no significant herniation compressing the roots.

You indicate that you had a nerve block but I am unclear as to what level and and type of injection (selective nerve root block, TFESI, epidural or ????). You indicate you had a foot drop after the injection. What this new and did this resolve?

What is your percentage of back and leg pain? Does this percentage change with standing and walking vs. sitting and leaning forward?

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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