[Jtal19305]

#22343

Hello Dr Corenman
I want to know if the approach to my spine issue was sound as I am experiencing nerve issues since my surgery about one year ago. My mri showed a large disk bulge at T12 L1 with stenosis and osteophytes. I also had advanced stenosis at L2 L3. I’m a 48 year old male. I had symptoms of leg weakness going into the surgery. The surgeon performed a posterior laminectomy disectomy Facetomy with interbody fusion at T12-L1 and added pedicle screws and rods at T12 L1. I also had an L2-L3 hemi laminectomy on the left side. I have read that nerve issues can occur with the type of fusion I had at T12 L1. And after my surgery the sole of my left foot had a severe burning pain. One year later I still have dysthetic burning pain in both feet and lower legs. The burning is not a strong as it was right after the surgery but it is unacceptable. I did not have this pain prior to surgery. I have seen other doctors after my surgery and some make comments that their surgical approach would of been different but done go into too much detail. They say each doctor has his or her own style. I have read that most doctors now approach my type of Compression differently because of thr nerve issues. I am trying to understand why I had the surgery that I did given the known risks. I have nerve pain now and I am upset that this could of been avoided. Any comments or suggestions would be appreciated.

Thanks
Jerry

[Donald Corenman, MD, DC]

#22344

There are basically three procedures to remove a disc herniation at T12-L1. These are the posterolateral approach, the direct lateral approach and the anterior approach. Each has its own benefits and pitfalls.

The posterolateral approach (which I use and which you had) approaches from the back and the side. The segment initially has a laminectomy (removal of the back wall of the canal) to allow expansion of the dural (nerve) sac due to compression from the herniation. Then the facet on the side of the herniation is removed and the lateral extent of the dural sac is exposed. The approach to the herniation is from the side under the sac without retracting this sac as the cord at this level is sensitive. I don’t perform an interbody fusion as the amount of retraction I feel is more than the nerves can tolerate but I do perform a posterior instrumented fusion to prevent recurrence of the herniation. Some individuals do not perform a fusion using this technique.

The direct lateral approach utilizes an approach from the side (through the psoas muscle and diaphragm) in a small incision made on the side. This technique uses a cannula to visualize the surgical site and a large cage is placed after the decompression to perform the fusion. Most surgeons then place posterior instrumentation to stabilize the level.

The third approach is direct anterior (but really from an incision on the side). The front of the disc is removed, the herniation is removed from the front, an interbody cage is place and then either front instrumentation is placed or the patient is turned over and posterior instrumentation is placed.

Your current pain one year later (“dysesthetic burning pain in both feet and lower legs”) is most likely from nerve root injury. This could originate from the surgery but also could be from the disc herniation that created the need for surgery initially. This pain can be treated with time (your pain is already diminished after one year) and can be expected to slowly diminish over more time but not completely disappear. Medications like Lyrica and Neurontin can be effective. Occasionally, epidural steroid injections can be effective and if the pain is really disagreeable, a spinal cord stimulator 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.

[Jtal19305]

#22353

Hello dr Corenman
In my case the procedure at T12-L1 was done through the back and an interbody fusion was done whether I needed it or not despite the risks you stated What would signify a nerve root symptom versus a spinal cord symptom versus a nerve symptom? In my case my left sole of my foot began a burning pain after the surgery and the dysthetic pain in my feet and lower legs continues to this day albeit the intensity of the pain is less than day one but still unacceptable. With the hardware at T12 L1, is it even feasible to install a scs? And if so would it help the feet? I’ve read good things about nevro hf10 unit which works at higher frequency and is less dependent on location. I have been patient but I’m concerned about symptoms. I was told only a ct myelogram would be definitive enough due to artifact from the pedicle screws and rods in my spine. Some tell me there are risks of further damage doing this imaging. I just wonder if something was accidentally cut or bruised while doing the decompression, removing the bone and disk. Or if this created more instability causing nerve compression which is the reason for my pain. One doctor mentioned that the mere opening or decompression of the cord could cause it to miscommunicate leading to pain. I find this counter intuitive as taking pressure off the nerve should relieve pain. I find myself confused and feisty over the approach my surgeon took because of the nerve injury risks despite this being a standard option. I am also finding that it is hard to get a new doctor as most will not see a patient until one year or more post surgery from the care of the original surgeon. I’m living in a new area so I need a new specialist. I’m almost at my one year mark. I hope to get better but I’m losing hope due to constant pain. Thanks for your input and advice. It is most helpful.

[Donald Corenman, MD, DC]

#22361

Spinal cord injury can be painless while a nerve root injury is always causes burning pain and dysesthesias (allodynia or painful touch of the skin and weird skin sensations without touch). Spinal cord dysfunction causes bowel and bladder dysfunction at this level along with sacral and coccyx symptoms. Surgery at the T12-L1 level with burning pain into the sole of the foot would mean to me injury to the S1 nerve or possibly L5 since these nerves exit the cord at about T9-10 level.

A spinal cord stimulator (SCS) can be implanted above the level of the fusion and directed either up or down depending upon the coverage necessary. I can’t comment on SCS models as I don’t implant these devices.

A CT myelogram can be useful for determining fusion status and also reveal any residual compression present. This study however won’t reveal injury to the root or cord. An MRI will reveal this injury and the metal artifact created by the implants should not be severe enough to distort the canal image.

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.

[Jtal19305]

#22405

I have this dysesthetic pain in my feet. The pain will vary and wax and wane. It will be in my left foot in the morning and by evening it is also on the top of my right foot and more pronounced aching pain in the sole of my left foot. The pain will travel to the lower legs just below the calves. A neurosurgeon I saw yesterday at a major teaching hospital in Philadelphia could not explain my pain nor tie to the surgery I had at T12/L1 or L2/L3. He seemed to think that nerve root injury at T12/L1 would cause pain along a longer path and include more of my leg. He thought I was decompressed at T12/L1 although my cord now “kinks” around the disk bulge at T12/L1 which I gather is the annulus and PLL (posterior longitudinal ligament).

The dr. indicated it could be RSD or CRPS caused possibly by the needles used for the neuro-monitoring during my surgery or some local trauma to my foot. He stated that it would not get better as it has been almost one year since surgery. He seemed to believe a scs could help and would involve a little more risk to install as the entry point would have to above T12 (my surgery and instrumentation level) where the space in between the vertabrae is narrower but he could still do it. He did mention that leads could puncture my cord and cause paralysis. This was not too reassuring to try out the procedure.

He also referred me to a pain doctor in the area. I was told the a sympathetic nerve root may help as it may act on the nervous system like re-booting a computer. Is this reasonable?

So I continue to struggle although I am being as patient as possible to allow time to heal, which in most cases, time does heal. However, I am concerned that my nervous system was “knocked” out of its normal operating range, and is malfunctioning causing the pain signals to fire recklessly. It has limited or no ability to self correct from what I can gather. Unless there is a way to get it to adjust to what it is correct.

Have you ever encountered anything like this or heard/read of this in medical literature? I am going to continue searching for help, and to find a solution for this.

[Donald Corenman, MD, DC]

#22412

If you had CRPS, you should have other symptoms than just burning dysesthesias. See https://neckandback.com/conditions/complex-regional-pain-syndrome-crps-reflex-sympathetic-dystrophy-rsd-causalgia/ to understand. I have never seen nor read about monitoring needles causing CRPS.

If a sympathetic nerve block does give you relief, this may help to point to CRPS as (a) the diagnosis. If you get an epidural injection at the surgery level (T12-L1) that gives you temporary relief (see pain diary), most likely that surgical level is the source of the current pain.

There are well skilled surgeons who can implant a SCS with reduced risk. You can call my office to get a referral surgeon who I trust.

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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