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  • AvatarDonald Corenman, MD, DC
    Moderator
    Post count: 7682

    It is possible but unlikely that this is SI pain. The most common LBP into the leg after a fusion surgery is nerve root irritation and then a seroma formation (a collection of fluid that can occur after surgery). WIth failure of dexamethasone over two courses and high levels of pain, a new MRI is warranted.

    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.
    AvatarprofessorW
    Participant
    Post count: 14

    My surgeon did order an MRI and below is the report. I continue to have almost constant LBP worse with sitting/lying/walking and it goes into buttocks and sometimes lower in leg. Particularly interested in what this means: “ There is also fairly strong postcontrast enhancement and high precontrast T2-weighted signal intensity around the disc space implant at L5-S1“

    Report
    Exam: MRI Lumbar Spine wo then w Contrast Date: 9/22/2020 8:35 AM
    History: 38 years old patient with M54.5 Low back pain; Technologist reports: Low back pain with left leg pain x 3 weeks. History of surgery August 25. 2020. No injury.
    COMPARISON: Lumbar spine July 23, 2020.
    TECHNIQUE: Standard sagittal and axial sequences were performed before and after contrast including fat-saturated postcontrast
    sagittal T1-weighted images. The patient received 15 ml of IV MultiHance. Exam is technically limited by susceptibility artifact
    from metallic hardware in the lumbosacral area..
    FINDINGS: There appears to be typical lumbosacral anatomy with five lumbar-type vertebrae, assuming T12 is the lowest rib-bearing vertebra. There are new metal artifacts from posterior spinal fusion
    at L5-S1 as well as a disc space implant at the L5-S1 level, also
    new. There is a small posterior midline incisional fluid collection
    at the level of the L4 spinous process down to the L5 spinous process but not atypical given the short interval following surgery (four

    weeks ago).There is no remarkable curvature on coronal images. There is been no change in alignment on sagittal images.
    There is also fairly strong postcontrast enhancement and high precontrast T2-weighted signal intensity around the disc space implant at L5-S1 (sagittal series 9, image 4 through 11). However, there are no reactive marrow changes subjacent to the endplates and no suggestion of erosive or subsidence changes in the endplates. There is no apparent change in the other disks with only very mild disc space narrowing at L4-5 and relative disc dehydration at L4-5 and L3-4.
    Vertebral body heights are well-maintained at all levels. Bone marrow is generally normal with no concerning bone marrow replacement or marrow edema at any level.
    The conus and intradural lumbar nerve roots have a generally normal appearance. Specifically, there does not appear to be any contrast enhancement of the nerve roots or adherence between nerve roots or between the nerve roots and the meninges to suggest adhesive arachnoiditis. Conus termination is at L1-2, which is normal. There
    is no evidence for epidural abscess, hematoma, or mass. On axial images:
    At T11-12, there is mild bilateral facet hypertrophy with no disc abnormality or stenosis.
    At T12-L1, there is no significant degenerative change or stenosis.
    At L1-2, there are no significant degenerative changes and no significant stenosis.
    At L2-3, there are no significant degenerative changes and no significant stenosis.
    At L3-4, there is no change in very small but broad central disc protrusion associated with an annular fissure at the posterior midline. There is still no central stenosis or nerve impingement.
    At L4-5, there is no change in very small broad central disc protrusion, also associated with an annular fissure in the posterior midline which has not changed. There is no nerve impingement nor significant central stenosis

    At L5-S1, there is fairly prominent right anterior epidural enhancing scar tissue which extends around the right S1 nerve sleeve and into the new right hemilaminectomy defect. Again, however, there is no epidural fluid collection. The right S1 nerve sleeve is not significantly displaced or effaced.
    IMPRESSION:
    1. Compared to MRI two months ago, patient has undergone anterior discectomy and fusion as well as posterior spinal fusion with
    hardware at L5-S1. Right hemilaminectomy also appears to have been performed. There is an enhancing tissue around the disc space implant at L5-S1, but the finding is of uncertain significance given the
    short interval following surgery (about one month). There are no convincing findings of postsurgical infection and there is no epidural fluid collection.
    2. Otherwise stable findings of mild disc degenerative change and very small broad central disc protrusions at L3-4 and L4-5. No lumbar nerve impingement or significant spinal stenosis demonstrated.

    • This reply was modified 3 weeks ago by AvatarprofessorW.
    AvatarDonald Corenman, MD, DC
    Moderator
    Post count: 7682

    Your notation “There is also fairly strong postcontrast enhancement and high precontrast T2-weighted signal intensity around the disc space implant at L5-S1“ is most likely from the surgical implantation and nothing else but with continued pain, an unlikely infection should be ruled out by obtaining labs.

    This notation “At L5-S1, there is fairly prominent right anterior epidural enhancing scar tissue which extends around the right S1 nerve sleeve and into the new right hemilaminectomy defect. Again, however, there is no epidural fluid collection. The right S1 nerve sleeve is not significantly displaced or effaced” indicates still some inflammation around the right S1 nerve root. The good news it that the root is not displaced (compressed) and you don’t have a seroma so you don’t have to worry about compression.

    The root however is aggravated and this might take about 3 months to calm down. Normally, oral steroids are helpful so I don’t understand why you gained no relief. With negative labs (no infection), a TFESI (transforaminal epidural steroid injection) can be helpful.

    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.
    AvatarprofessorW
    Participant
    Post count: 14

    Thank you! All my pain is actually on the LEFT, and the MRI indicates the inflammation on the right. Is there anything explaining LBP (worse than leg pain but some leg pain) on the left? My surgeon wants me to have a diagnostic SIJ injection.

    • This reply was modified 3 weeks ago by AvatarprofessorW.
    AvatarprofessorW
    Participant
    Post count: 14

    Thank you! All my pain is actually on the LEFT, and the MRI indicates the inflammation on the right. Is there anything explaining LBP (worse than leg pain but some leg pain) on the left? My surgeon wants me to have a diagnostic SIJ injection.

    I should add that I don’t have back pain on the right. On the right, I do have annoying muscle fasciculations in my calf, as well as some fullness/numbness in my foot at times. This could be from the inflammation of the right S1 nerve?

    AvatarprofessorW
    Participant
    Post count: 14

    I should note that pre-fusion I did not have this pain/fullness in my foot, nor the fasciculations on the right. My main symptom was weakness, which is resolving, and calf pain (just not too much foot pain, which is where it is now). Could the irritated S1 on the right, per the MRI, cause the fasciculations and foot discomfort? I haven’t talked to my surgeon about these, so not sure if they can be treated…but they are extremely annoying.

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