[Michaelrch]

#24110

Hi again Dr Corenman

I hope you are very well. Thanks again for your response. As always, read with interest.

Re the ESI treatments, I understood from some articles on the web that there is a variant of the ESI that also introduces an enzyme to break down scar tissue. I think it’s Hyaluronidase. I gather this is referred to as lysis of adhesions or Adhesiolysis. I found a couple of studies in the nih.gov site that seem to suggest that it can result in better outcomes than PT alone. E.g.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3903797/
Is this something you would consider in a case where the presence of scar tissue is causing ongoing pain?

In my case, I think that I have maybe kept the nerve moving as my flexibility is not too bad, but aside from sitting which is always trouble after a while, even lying down and other positions where I have pressure on my lower back cause pain after a while (I have developed a habit of lying in positions that raise my left side up slightly to compensate), so I am thinking that there is just too much tissue around the nerve and it is keeping the nerve under pressure all the time. Standing for short periods or walking relieve the pain as I guess they are not mechanically causing the pressure on the area. Anyway, that’s a bit of a digression. Sorry.

I will be speaking to the radiologist who has done my 3 ESIs next week. Is it worth me asking about lysis using enzymes and steroids or is it just not an accepted treatment among serious and professional practitioners?

Thanks again for your assistance. It’s really much appreciated.
Michael

[Donald Corenman, MD, DC]

#24111

I have never ordered Hyaluronidase for my epidural injections. I have read the available papers (few) which note improved results but I am unclear if this enzyme will break down scar tissue as this tissue is made up of much more than hyaluronic acid.

Neurolysis is probably not what this adjunct medication does and I am apprehensive about new and relatively untested substances but there is a paper where this medication was injected intrathecally without consequences. It might be safe but again-I an not clear about this and would not recommend at this time.

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.

[Michaelrch]

#24441

Hi again Dr Corenman

Since my last post things have remained more or less static. I saw my old, trusted GP and he tried oral steroids again to see what would happen. 80mg down to 20mg Prendnisone over 16 days. It had some effect lessening the intensity of the nerve pain, but it has gone back to the status quo ante again now. He told me to arrange another appointment with his favoured surgeon (the one I saw a couple of times late last year). This is booked for next week.

It seems like I still have something that is irritating the nerve and I am supposing it’s scar tissue. I am also thinking that aside from tethering, the physical presence of the tissue is causing an issue. I often get some of the worst pain when I am just lying in bed (on my back or side) or else when in a reclining chair, so not when I am really stretching or moving anything. Oddly and fortunately, somehow it is less when I sleep so I don’t tend to wake up from the pain. I have a reasonable amount of flexibility (i.e. At a push I can reach out and touch my toes both sides) but I don’t push that too much.

The pain in my spine has come off quite a bit I am pleased to say. I swim 15 mins 650m every day at present and am incrementing that about 50m every 5-7 days. A few months back that would have really hurt my spine and left a band of pain either side of my l5 but that doesn’t happen now. Walking downhill for a while can be a problem so I figure that is mechanical shock absorber issues due to the lack of disc tissue.

So my issue remains this nerve pain. It varies a lot from day to day. Sometimes it’s in the calf. Sometimes I have burning feeling in my heel. Sometimes I have pointed aching in my thigh or glute. On bad days it is high up near the disc but off to one side, so basically anywhere along the S1 dermatome. Usually a combination of a few of these on any given day. The intensity varies quite a bit as well and without any reason that I can figure out, which is a bit grim. I can have a couple of good days and then wake up one day and it is just inexplicably worse again, and I have to be careful all day and spend much of the time bed.

So, I wonder if you can give me advice for when I see the surgeon next week? Should I be asking about neurolysis to free up the nerve? I read a paper from NICE in the UK that had about 50% of people getting benefits from what they referred to as adhesiolysis.
https://www.nice.org.uk/guidance/ipg333/evidence/overview-314283853

Otherwise is there anything else that you could suggest or recommend?

Many thanks again for your time and help. It is much appreciated.
Michael

[Michaelrch]

#24467

Hi again Dr Corenman

So I went to see my new surgeon today. We chatted through the options. We discussed 2, first, neurolysis and second, putting in screws with a pair of semi flexible cords at the back to reduce mobility and support the spine. He does not like fusion much.

Looking at the last scan he is still pointing at something that could be a disc fragment alongside the nerve and that is slightly distorting the shape of the swollen nerve. He is not certain though and this would contradict what the radiologist who did the MRI thinks (i.e. nothing but scar tissue). He also sees the disc tethered just as it exits the foramen.

I asked if the neurolysis could be done without cutting me open. The study I mentioned in my last post actually talks about going in with a catheter guided by fluoroscopy and feeding tools in using that. He says that would not be appropriate as its much too deep and close to the spinal cord, so he would go in laparoscopically, like the original microdiscectomy. I was concerned about additional scar tissue build up. He said that it was a risk but I would be unlikely to end up worse than I am now, given he is looking to open up the space again and maybe shave off some neighbouring bone to make more space. Bottom line he thinks this option has a 60% chance of success.

We discussed the pedicle screw option. He is confident about this and says he has used it with athletes etc successfully. He said that this solution would have the benefit of preventing the hypermobilty that the shrunken disc is allowing and would therefore protect the nerve because the nerve would not be moving around so much plus the disc would be under less pressure and less prone to any bulging into the nerve, but I would of course lose about 50% mobility in the joint. He thinks this option has 85-90% chance of success, just with the bigger side effects and longer recovery time,

On balance my wife and I decided that the less invasive option was the better option for now. I can always go back and have the screws in later if it does not work. We agreed that We would know if that was required 3 months post op.

So now I am booked in to have the neurolysis on the 6th April.

Right now my pain is only minor as I am doing everything possible to avoid annoying the nerve. So I don’t sit or drive much, I do little stretching or mobilisation of the nerve, I swim 750m every day which I can tolerate ok now, even working reasonably hard. I sometimes think it is overkill to have surgery again but then I have nothing like a normal life right now. I have just got used to it I guess! As my wife said, not being able to sit comfortably really limits life a lot. That is where I am now.

Does all this seem sensible? It’s a while until my surgery so I have a while to reconsider…
I would really appreciate your thoughts, especially if you think there are risks that I have not considered.

Many thanks as always
Michael

[Donald Corenman, MD, DC]

#24468

Do not do the “pedicle screw option” as you don’t need metal or plastic in your back that will not lead to a fusion (and you don’t need a fusion). So the question is could you benefit from adhesolysis? His percentage success rate of 60% is similar to the 50% quote I give to patients. The problem is that the nerve could be intrinsically damaged (inside the nerve sheath-something like the wire damaged inside insulation) and there is no way to predict this. Neurolysis is also technically tricky so I assume this surgeon is a “master surgeon” and will take good care of you.

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.

[Michaelrch]

#24476

Hi Dr Conernman

Many thanks for your quick response. It was a bit of splash of cold water but that is what I am after so I can make the best choice.

Re the surgeon, he is a professor of neurosurgery, I just found he was president of the Swiss society of Neurosurgeons a few years ago, and was recommended to me by our doctor of 12 years who has not put us wrong before, so I am not minded to question the surgeon’s technical skill in doing a tidy job. I understand your point about nerve damage, I guess there is no predicting that. The only thing I can say is that the scans do show scarring adjacent to the nerve at the foramen as well as something the surgeon still suspects is disc tissue next to the nerve, compressing it slightly.

Re the pedicle screws, you say no to doing that without fusion. Does that mean you are not an advocate of dynamic stabilisation systems? I know the one that everyone seems to study is Dynesys. I asked the surgeon if that is the one he uses. He said no, he uses something newer – similar principles but more effective. He says to expect about 50% less motion with such a system rather than 100% less motion with fusion. He does not like fusion because of the loss of motion and the danger of cascading disease in adjacent segments. He suggests considering stabilisation to stop the slight bulging of the disc (when sitting etc) pressing into the nerve which is tethered at the foramen and can’t get out of the way, hence pain. His theory is stabilisation and support from the screws/cords stops the disc bulging, so the nerve is not under pressure, so reduced pain. Plus the stabilisation does partly stop motion, so less demand on the nerve to move around, so even if it is tethered then it is not being yanked around when the scar tissue doesn’t want to let it.

Thanks again for you thoughts
Best regards
Michael

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