[DaniS]

#21250

Dear Dr. Corenman,

My husband underwent a microdiscectomy on the 22nd December 2015 on L4-5, L5-S1 – prior to surgery he had pain in his left leg some loss of sensation in his left foot and some very minor weakness on examination but was still working and functioning. The day after surgery it was noted his left foot had rotated outwards which prompted a referral to physiotherapy but he was discharged as expected from the hospital. Around 2 weeks later his left knee began to buckle on every step – this was a new symptom which has never happened before. He attended his physiotherapy appointment 3 weeks post surgery and was immediately told he would need an Mri and given a crutch. The hospital called him in the next evening and over the course of the next week he had an MRI no contrast, a CT and then another MRI (he was also starved on 3 days for surgery but then they changes their minds). He was told lots of different thing such as they saw bubbles, fragments and that they saw nothing amiss except a little scar tissue. He has been offered a nerve root block as he had had some more pain but that seems to have subsided (however they have still sent an appointment), a nerve conduction study has been ordered but we are still waiting 6 weeks post op now. He has another physio appointment in 2 weeks time. He has a lot of weakness in his left toes, foot, ankle and apparently hip but the biggest issue is the buckling knee.

My husband is a bricklayer by trade and was working full time pre op and now is unable to work or drive (we have a manual car and we would not be insured), I suppose my question is is the left knee buckling to do with the surgery and is it likely to improve? He has become very disheartened with everything and wishes he had not had the surgery.

Below I have added information from his discharge notes and a letter sent to our gp as we have also received a copy.

DISCHARGE NOTES

L5 S1 sciatica secondary to left L5-S1 L4-5 disc prolapse – microdiscectomy to both – both hard disc material but removed successfully. There was also a L3-4 disc prolapse but this did not correspond to patient symptoms. Patient advised further surgery for L3-4 may be required in the future.

Letter to GP sent after readmission to hospital and follow up a week after that (4 weeks post op)

There is complaint of numbness in left lower limb (which sometimes buckles) and left ankle (the foot deviates out while walking). On examination his straight leg raising is diminished to 45 degrees on the left side. Normal tone and bulk of the lower limb muscles. Peripheral pulses intact and no pain on passive movement of his hip joints. Left lower limb is weak with MRCS grade 3/5 at EHL, 3-4/5 at left knee extension, 4+/5 at hip flexion and markedly reduced hip adduction with power of 2/5. All lower limb reflexes intact expect absent at left ankle jerk. Hypoaesthesia noted in right sided L5-S1 dermatomes and left sided L2-L3-L4-L5-S1-S2 dermatomes. Bilaterally downgoing plantars.

We spoke to the GP and he thinks this happens to be a coincidence and that we should talk to the physio. We are getting little or no information and most certainly not in English! Please can you offer some insight, advice or simply a translation.

Many Thanks

Danielle

[Donald Corenman, MD, DC]

#21262

Lets break down what occurred in surgery and then what symptoms your husband has as related to what can cause these symptoms.

You husband initially had a microdiscectomy at L4-5 and L5-1 on the left side. Generally, this surgery is for herniated discs at both levels that would compress the L5 and S1 nerves. These herniations could cause leg pain from the buttocks down to the bottom of the foot and weakness of the foot muscles (dorsiflexion and plantar flexion-bringing the foot up and pushing the foot down). See the section https://neckandback.com/conditions/symptoms-of-lumbar-nerve-injuries/ and https://neckandback.com/conditions/home-testing-for-leg-weakness/ to understand what specific symptoms are generated by each nerve and how to test these nerves at home.

I am unclear if he was “worse” after surgery (greater weakness or more pain or both). Two weeks after surgery, he developed knee or quadriceps weakness (” Around 2 weeks later his left knee began to buckle on every step”). This is an L3 or L4 nerve involvement and what seems to be a new finding. This nerve passes by the L3-4 disc and exits out of the L4-5 foramen (see lumbar spine anatomy). There are two possibilities for L4 nerve involvement.

One is the unaddressed L3-4 disc herniation (“There was also a L3-4 disc prolapse but this did not correspond to patient symptoms”) which could be causing your husband’s knee buckling as this will compress the L4 nerve root. The other possibility is a lumbar far lateral disc herniation at the L4-5 level that could have been missed and is compressing the L4 nerve root in the foramen (less likely but possible). Far lateral disc herniations are sometimes missed by radiologists.

There is obviously something wrong and this problem needs to be addressed sooner than later as motor weakness in the legs is a more difficult problem to heal.

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.

[DaniS]

#21286

Hi, Thank you for your reply, My husband was pain free for a day or so post surgery followed by an increase in pain which seems to have resolved at the moment. The weakness and buckling is new – he had slight but barely noticeable weakness and numbness on both sides of his foot pre-op but was still running up and down ladders with 8-12 bricks at a time. The overall weakness is totally new and developed over the first 2 weeks post-op which is why I wondered if it was a complication that you had seen before. They have not mentioned that the L3-4 bulge is bad enough that they would expect symptoms (would this not be first thing they would suspect) During his extra stay at hospital 3-4 weeks post-op they mentioned seeing debris, bubbles and finally a little scarring- they starved him for 3 days of the 8 day stay telling him they would be going back to operate again but changed their minds repeatedly. According to the GP the first operation is a resounding success as he seems to be pain free in his leg but it is simply not that clear cut for us.

He has Physio on on the 16th Feb, a nerve root block booked for the 23rd Feb and NCS booked for the 29th Feb. Can you advise me on the questions we should be asking or information we should be looking out for. I am concerned that it will not be figured out before the damage is irreparable. Would it be a bad idea to ask for some kind of knee brace to help lock his leg so he can walk without crutches? This is a huge deal to us and my husband is not taking this very well and really regrets getting the op done in the first place as now he is unable to do much without a lot of difficulty – he can’t even drive anywhere as we have a manual car so we are not insured because of the weak knee.

I really appreciate you sharing your knowledge and experience here as you do, to help people like us understand the jargon and such a little better.

Many Thanks

Dani

[Donald Corenman, MD, DC]

#21290

This needs to be addressed soon. There are new and progressive neurological symptoms that the cause needs to be diagnosed. These changes have a cause, whether they are from surgery, the non-addressed L3-4 level or something else. An EMG test can be helpful but the muscle strength examination should be plenty to convince the physicians that another process is present. I think you need to push the issue and don’t take neglect as the current status.

Enforce the question of new onset weakness of the quadriceps muscle. This was not present before and is present after surgery. There is a cause for this. This must be diagnosed and treated.

Yes, a drop-lock hinged knee brace can be used in the meantime to help your husband ambulate. This brace can be locked to prevent knee collapse (bending) but then “unlocked” when he needs to sit down.

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.

[DaniS]

#21708

Hi Dr. Corenman,

I was hoping I would be able to give you a positive update however, unfortunately this is not the case – my husband has been for the nerve conduction study (the nerve root block was cancelled due to the pain no longer being an issue). As far as we can find out at the moment (from the physio) the S1 nerve showed damage, explaining the lack of response with his ankle, however we were told the rest of the nerves show up as fine (we have only had 2 minutes of vague information). We are now 3 months post op and his knee still buckles at every step and it is not improving – they have him attending the physio twice weekly to go on gym equipment but after more than a month he feels that there is no improvement and that his “good leg” is doing all the work – if he removes his good leg the left “bad” leg cannot hold weight or move weight. The physio has said that seeing the NCS showed no damage to the other nerves then the prognosis in his and the consultants opinion was good – I do not know how they can say this – am I missing something? We are supposed to be getting an appointment to see the consultant soon (we haven’t seen him since around 4 weeks post op on the ward), are there any suggestions you can give me to ask him when we see him to try and get some answers or further tests?

Many thanks

Dani

[Donald Corenman, MD, DC]

#21732

If your husband still has significant weakness of his knee (and his knee itself is OK-no ACL tears or knee ligament instability), then this is an L3 or an L4 problem. Did the neurologist also examine your husband or only perform the EMG test? It seems with a preexisting and known L3-4 HNP and quadriceps weakness (the muscle that straightens out the knee), another set of eyes would be in order (another consultation). I would be suspicious of the neurologists consultation.

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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