[Donald Corenman, MD, DC]

#26913

I am confused. Did you have mainly leg pain from the recurrent herniation or instability and significant central lower back pain? I thought mainly leg pain. If back pain was predominant, then a fusion should have been considered as these “dynamic stabilization” devices work poorly.

The thought with these devices are that they “restrict motion” but do so poorly by tethering the very back of the spine but attach with pedicle screws that place the center of rotation behind the spine. This is somewhat complicated but the center of rotation should be in the middle of the disc space and never behind the vertebra. This device overloads the disc and causes problems including pain and dysfunction.

I have never put one of these devices in but my desk drawer is full of these devices as I have taken many out.

Be careful with the diagnosis of SI generated pain as I just wrote a paper indicating that 94% of sacroiliac pain is generated mainly by the lumbar spine.

Did this surgeon at least take out that recurrent disc herniation?

Before you enter any further surgical adventures, you need to know where your pain originates. This first needs to be generated by a thorough history and physical examination, a thorough review of all X-rays, MRIs and CT scans and then blocks of nerves, hardware and possibly discograms.

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]

#26926

Dear Dr Corenman

Many thanks for you quick response.
In answer to your question about my symptoms before this last surgery, I had both leg pain, especially after standing for a while or sitting for relatively short periods, and I also had central Back pain if I did anything that required “shock absorbing” in my lower back e.g. walking downhill and a certain gym machine where you stand on elastic bands that are free to move up and down and you have to stabilise yourself on them.

Re the herniated disc, from the consults I have had, yes the surgeon says he does not see any further herniation though it has to be said that a) any previous herniation was not much evident on previous MRIs and
B) he did not see much of a herniation when he actually operated and opened my up.

The reasons for believing that some of the pain I have now is Si joint pain are
– that it gets worse after walking (not the case before this surgery)
– I have pain on the outside of the thigh and sometimes into the hip as well as in the back of the leg,
– I have had injections into the joint and they do work a bit, albeit nothing amazing.
– I cannot lie on my left side at all without causing pain.
– some of the physical movements to provoke SI joint pain are positive though not all
– the first steroid injection I had in the joint (about 3 months ago) caused a very strong immediate reaction in the local area – actually it felt like someone had just taken a big hammer to my backside but I figured that was a reaction to the injection into a highly inflamed joint

Reasons to believe it might not be are
– I had an RFA and it did not fully clear up the pain in the joint
– I have had several steroid injections and continue to get buttock and leg pain after walking too much or doing the wrong exercises

Other symptoms right now are
– I cannot stretch my hamstring without causing an instant and long lasting painful reaction in my S1 nerve
– I can’t sit for more than 5-10 minutes without first getting back pain then getting long lasting leg pain afterwards
– I can’t lie on my back without getting pain in my back (I think my L5S1 facet joint) and also almost instant tingling then pain in my buttock and leg (so I have to lie on my right side, without exception which is infuriating)

Those last symptoms do suggest that something is pressing the nerve directly rather than the nerve pain being the result of an inflammatory problem in the SI joint. The problem with lying on my back only appeared after doing some exercises to strengthen my glutes and hip abducttors and adductors (to stabilise the SI joint) which involved a slight twisting of the hips. I put (past tense) it down to further irritation of the SI joints or facet joints but, in hindsight, I guess the sheering motion could have caused further deterioration of the disc…

Do you have any thoughts regarding the stiffness if the rest of my lumbar spine? I have a feeling that if I don’t remedy that, anything else I try will be futile as so much load is currently being put on the bottom segment and the SI joint.

Also, should I not be worried that if the existing stiffness and stabilisation is already causing SI joint dysfunction then actually fusing the L5S1 would not make that dysfunction even worse?

Re your study, how did you conclude that the SI joint pain was actually caused by the lumbar spine?
My surgeon said that a problem with the L5S1 disc could “entertain” a problem in the SI joint but I had no idea what he meant. It sounds akin to what you are suggesting.

Thanks very much again
Michael

Ps I have tons of images that I could send you. I know you charge for looking at those. How could I arrange a consultation on that basis and get an idea of costs etc?

[Donald Corenman, MD, DC]

#26928

In my study, I took all patients that had majority pain in the SI joint and did a complete work-up to determine pain origin. Fully 94% of patients had pain originating from other than the SI joint meaning the SI joint only causes 6% of pain that localizes to the joint. SI joint tests are worthless as they are accurate only 10% of the time.

SI joint syndrome is diagnosed by first making sure the other sources of potential pain are ruled out (a diagnosis of exclusion). Then, an injection into the joint needs to yield great temporary pain relief (pain goes from a 7 to a 1 for the first three hours before increasing after the numbing medication wears off). That injection result needs to be repeated duplicating the same great relief. Only then can an SI joint syndrome be correctly diagnosed. Radio frequency ablations (RFA or rhizotomies) are poorly effective as only 50% of the nerves can be ablated (the anterior nerves are unreachable).

Your symptoms don’t look to point to the SI joint
“that it gets worse after walking (not the case before this surgery)
– I have pain on the outside of the thigh and sometimes into the hip as well as in the back of the leg,
– I have had injections into the joint and they do work a bit, albeit nothing amazing.
– I cannot lie on my left side at all without causing pain.
– some of the physical movements to provoke SI joint pain are positive though not all
– the first steroid injection I had in the joint (about 3 months ago) caused a very strong immediate reaction in the local area – actually it felt like someone had just taken a big hammer to my backside but I figured that was a reaction to the injection into a highly inflamed joint.

I suspect the dynamic stabilization device is causing new pain.

Your current symptoms;
– I cannot stretch my hamstring without causing an instant and long lasting painful reaction in my S1 nerve
– I can’t sit for more than 5-10 minutes without first getting back pain then getting long lasting leg pain afterwards
– I can’t lie on my back without getting pain in my back (I think my L5S1 facet joint) and also almost instant tingling then pain in my buttock and leg (so I have to lie on my right side, without exception which is infuriating)

All these sound like radiculopathy and instability. I think you need a workup including CT scan, MRI and flexion/extension X-rays as well as a careful examination.

I do have a long-distance consult service. Please call 888 888-5310 and ask for Lori.

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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