[Ella]

#27981

Dr. Corenman,
Thank you for your amazing service to the community! I am grateful for it. Would love your view on the following:
Right leg nerve pain started mid December. Pain was worse during transfers (from sitting to standing or lying to sitting) and was alleviated by lying down on my back and walking. Pain stopped at thigh. MRI showed massive herniation at L4/L5.
Key MRI findings were:
At L4/L5 there is disc degeneration and herniation, and a sequestered fragment posterior to the proximal body of L5. It measures 6.2mm x 18.2mm and it is right paramedian. There is severe bilateral foraminal stenosis and right lateral central canal stenosis. All else appeared normal.
I did a course of steroids and started physical therapy (Mackenzie protocol) on Dec 26. My pain was reduced to 0/1 although my mobility took time to recover. After six weeks of physical therapy, I felt I had made a great recovery but then I had a flare up which appeared right after elliptical exercise. This time it was my low back that had excruciating 8/10 pain but not my leg.
I received a steroid injection on Feb 17 and following two days I experienced the worse pain ever. Could not move my legs for a couple of hours. I have improved very slow and incrementally since Feb 19 but I still wake up every 3-4 hours at night due to my right leg (shin and calf area in particular) feeling like an elephant has sat on it. Pain is alleviated by walking and standing or sleeping on my stomach. Pain is now 4/10 and appears to have plateaued in the last three weeks. I am now considering and have been scheduled for a microdiscectomy.

My questions are:
1. Why did the nature of my pain change after the steroid shot to where lying on my back is most painful when that was my relief position prior to the epidural?
2. What is your view on surgery for me who has tried conservative treatment for 3-4 months but now is dealing with interrupted sleep by a type of pressuring pain in shin and calf? My pain during the day is 1/10, its primarily the sleeping that aggravates it so much but most of it goes away after stretching and one/two ibuprofen pills.
3. I understand that the size of herniation is not indicative for surgery, but am concerned with fragments migrating if left untreated etc. What are the chances of that?
Kind regards,
Ella

[Donald Corenman, MD, DC]

#27983

There is an unanswered question; did you have any motor weakness with this large herniation? If so (and I would expect tibialis anterior weakness or “foot drop” with an L4-5 extruded HNP) then you should have considered surgery instead of a steroid injection. That is water under the bridge now unless you still have weakness in which case surgery is still an important consideration.

Steroid injection, even in the best of hands, can cause pain due to the fluid wave which takes up space in the canal. Nonetheless, a meticulous,experienced injectionist has much less problems with “pressure injection pain” than one in a hurry.

The steroid reduces inflammation. Nerve symptoms “heal” with centralization. That is, pain recedes in a distal (foot end) to proximal pattern. With a steroid injection, pain should be gone in the leg and buttock but if it doesn’t fully disappear, it can stay in the back (on the side of the herniation). Why it occurred only in your back while lying down I cannot answer. Night pain is not uncommon with an HNP as the herniation material is hydrophilic (it “loves” water and acts like a giant sponge). At night, gravity is removed when you lie down and water can absorb into the HNP causing further nerve compression.

Actually, size can be important in a herniation. The larger the HNP, the possibly more compressive it can be on the nerves. Extruded HNPs, like yours can migrate in the canal or occasionally migrate out of the canal but don’t count on it to happen this way.

In my book, with no motor weakness and the ability to function (walk and do your job to a degree), you can watch a hernation for three months with therapy and injections. If the patient is not 50% better in that period, a surgical discussion will take place with all the benefits and risks of a microdisectomy. Of course, if there is motor weakness present, a surgical discussion is immediately proposed.

See https://neckandback.com/conditions/home-testing-for-leg-weakness/
and https://neckandback.com/treatments/when-to-have-surgery/

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.

[Ella]

#27986

Dr. Corenman,

Thanks so much for the most thorough response I have received. Much appreciated.

I have never experienced foot drop and I have done the tests you recommended and don’t notice a difference. I have seen two neurosurgeons who have not noticed any considerable motor weakness. I have another MRI on Tuesday and will see if anything is different. Currently, am able to maintain a full time job with no pain during the day but still wake every once a night with leg pain that goes away after stretching/walking/ibuprofen. I just resumed driving two days ago. But my quality of life is still compromised due to lack of continuous sleep. I am 40 year female.
Two more questions if you don’t mind:
1. What’s the likelihood of a successful microdistectomy with my size? Rest of my discs seem normal but there is a small annular tear at L5/S1 but no herniation. Is there a higher risk of complications given there will be more area to manipulate?
2. What is the chance of recurrence? What can I do to minimize?

Thanks so much again!

[Donald Corenman, MD, DC]

#27996

The chance of your satisfaction from a microdisc surgery in your case should be 90-95%. Complications should be minimal.

Whether you choose to have a microdiscectomy or not, your recurrence chances are about 10%.

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.

[Ella]

#28026

Dr. Corenman,

Just wanted to update you and the community (in case there are others in my shoes) that my repeat MRI, about 4 months post the first one, showed that herniation is stable and unchanged from previous one and that “there is a large soft, posterior lateral herniated disc with inferiorly migrated fragment on right side. This measures 1cm x 1.5 cm x 1.5 cm by transverse by craniocaudal dimensions. This compresses the ventral dural sac on the right side and the right L5 nerve root. All other discs are unremarkable.” To my naked laywoman eye, the herniation seemed even bigger than before…but I am not a radiologist.

The hopeless optimist in me was hoping for some shrinkage especially having read several recent research articles stating that the largest herniations have the most likelihood of absorption. Is there any validity to those studies or am I the exception? Does that mean the disc is less likely to re-absorp if I wait?
I am scheduled for microdistectomy next Thursday. My symptoms are the same (no noticeable motor weakness, but discomfort and pressure pain that wakes me up at night but slightly improved. Is it worth me waiting longer given my symptoms have slightly improved? Now I can sleep for 6 hours versus four hours before woken up by pain. Or will I risk nerve damage by waiting?

[Donald Corenman, MD, DC]

#28048

There is the chance of herniation shrinkage but don’t expect that to happen, especially if it has been some months from the initial herniation. The longer a fragment is in the canal, the higher the change of it getting adhered in place due to scar. You are probably at the “tipping point” where you should consider surgery. The longer the fragment is present with symptoms, the lower the chance that surgery will yield relief. You could still wait as there is no specific study to indicate that you have to have surgery.

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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