Continued Pain 3+ months post microdiscectomy

Tagged: microdiscectomy

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Outdoorsy
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December 2, 2020 at 7:59 pm

Post count: 5

#33428

Dear Dr. Corenman,

I herniated my L5/S1 disc in February 2020. It was a 6 mm left lateral disc herniation that displaced the S1 nerve posterior laterally. Due to Covid, I didn’t start PT until early May. In June I saw a surgeon because I continued to experience buttock, back of leg and foot pain. Surgeon recommended surgery but I wanted to avoid it. I agreed to another MRI to see if there was improvement which occurred in July. The MRI results showed I still had a 6mm disc herniation but this time it was classified as an extrusion. On August, I finally had a microdiscectomy, after my pain symptoms intensified.

Recovery went well initially. I never had to take any narcotics post surgery. I suppose I have a high tolerance for pain. By three weeks I was walking 2+ miles a day. I started PT at 6 weeks and have been diligent in doing my exercises. I’m also walking 4+ miles a day now. Around the 5th week, I started to get some radicular pain on my buttock, thigh, leg and foot. However, instead of it being in a straight line, like pre-surgery, it was more a patchwork. I also started to experience pain in parts of my leg and foot that are not associated with L5/S1.

I got another MRI this past Monday and this is what it reads:
L3-L4: There is a 1.7 X .4 X 3mm left foraminal and paracentral disc extrusion which displaces the left L3 nerve root within the neural foramina. The left L4 nerve root is displaced within the lateral recess.
L4-L5: There is a 1.2 X .03 X 3.6 mm disc extrusion with spondylosis which displaces the L5 nerve roots within the lateral recesses. Central canal and neural foramina are patent.
L5-S1: Operative changes of left laminotomy are noted. There is a recurrence/residual left foraminal 1.3 X .4 X 2 mm disc extrusion which displaces the left L5 nerve root wihtin the neural foramina. The left S1 nerve root is displaced within the lateral recess.

My MRI from July 2020 reads:
L3-L4: At the L3-L4 disc space, there is a 3 mm far left lateral bulging annulus with minimal distal foraminal stenosis. Disc is seen contiguous without displacing the sensory root ganglion. There is a minute Schmorl’s node of the superior endplate.
L4-L5: At the L4-L5 disc space which is desiccated, there is a minute Schmorl’s node of the superior endplate and a 2 mm bulging annulus without central or foraminal stenosis.
L5-S1: At the L5-S1 disc space, there is a 6 mm left lateral extruded disc herniation displacing the left S1 nerve root posterior laterally. There is no central canal stenosis. There is a quite capacious spinal canal. There is no foraminal stenosis.

What would you recommend as a next course of action? I’m meeting with my surgeon on Friday to go over my MRI results so I’m curious as to your recommendations. I am a 44 year old female who was extremely active prior to this injury. I did sprint triathlons, ran and did boot camp style workouts 4 days a week. I can’t help but feel those days are behind me now.

Donald Corenman, MD, DC
Moderator

December 3, 2020 at 4:01 am

Post count: 8660

#33431

Well, unfortunately, you have a genetic variation of weak annular collagen and you have discal tears at the lowest three discs in your back. You have developed a far-lateral herniation at left L3-4 that is of significant size (” 1.7 X .4 X 3mm left foraminal and paracentral disc extrusion which displaces the left L3 nerve root”).

L4-5 is also mild-moderate HNP and is probably causing symptoms (“1.2 X .03 X 3.6 mm disc extrusion with spondylosis which displaces the L5 nerve roots within the lateral recesses”). This one is brosd based and thin (.03mm) so it might not be a significant pain generator.

L5-S1 has a recurrent HNP compressing your S1 nerve root (“At the L5-S1 disc space, there is a 6 mm left lateral extruded disc herniation displacing the left S1 nerve root posterior laterally).

Part of what you should consider depends upon your current symptoms and findings. Do you have weakness of your left quad muscles (squats) which is what the L3-4 HNP can do? If so, surgery is advised with a far lateral approach. If not, maybe you could try an injection (TFES!). Same for the recurrent HNP at L5-S1. Do you have calf weakness? If not, an injection can be helpful.

You have to start considering managment of these disorders as the only other choices are microdiscectomies and if continued recurrence, fusions which are not the end of the world but better than continued leg pain.

See;https://neckandback.com/conditions/symptoms-of-lumbar-nerve-injuries/
https://neckandback.com/conditions/home-testing-for-leg-weakness/
https://neckandback.com/conditions/far-lateral-disc-herniations-lumbar-spine/
https://neckandback.com/treatments/epidural-injections-and-selective-nerve-root-blocks-diagnostic-and-therapeutic/

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.

Outdoorsy
Participant

December 3, 2020 at 6:00 pm

Post count: 5

#33439

Thank you Dr. Corenman for your time and knowledge. You stated what I feared and suspected, that this is likely a genetic disposition.

I did make one critical typo. My L3-L4 herniation measures at 1.7 X 0.4 X 1.3.

I did test for weakness for L4, L5 and S1 and found there are none. My pain is mostly from S1. However the reherniation is much smaller now than pre-surgery which was at 6 mm.

I’ll keep you and the forum posted after reviewing my condition with my surgeon tomorrow. Thanks, again.

Donald Corenman, MD, DC
Moderator

December 5, 2020 at 8:50 am

Post count: 8660

#33444

Thank 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.

Outdoorsy
Participant

December 7, 2020 at 1:19 pm

Post count: 5

#33449

I spoke to my surgeon to review the MRI results. He asked what my symptoms were. He said he likes to review the images himself and not rely only on the MRI report and thought my spine looked good. The other findings were not visible without contrast and he was not concerned. He told me to keep up with PT, no physical restrictions. I will continue with walks (4+ miles a day) and PT and nothing else. I am getting a TFESI at L3/L4 and hope it does the trick.

I need to maintain a positive outlook. I do believe there is a psychological element to feeling pain and healing and it helps to believe and work toward the best chance to a full recovery.

Donald Corenman, MD, DC
Moderator

December 8, 2020 at 8:18 am

Post count: 8660

#33450

Make sure that you keep a pain diary after the TFESI. See https://neckandback.com/treatments/pain-diary-instructions-for-spinal-injections/

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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Donald Corenman, MD, DC

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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