Tagged: Microdisectomy rehabilitation
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I have learned a lot in the process of understanding my injury and have been amazed at the beauty of the human body, the processes of medical science and the generosity it’s practioners. Thank you for what you do.
On 11/17/17 I underwent successful microendoscopic discectomy at L5-S1 for severe left side radiculopthy and I haven’t required anything stronger than Ibuprofen and acetaminophen since, and that sparingly. I have been walking three to four miles throughout the day, with my leg pain all but gone and it’s function returning nicely. There is some occasional sharp shooting pain at the nerve root radiating not beyond the buttock, which I sense will get better in time, especially as my muscles regain strength.
While my surgeon was skilled, gentle and polite, he hasn’t been much for care outside of surgery. My consult was less than 15 minutes and he said I wouldn’t need to follow up with him. He did agree to follow up at two weeks, but it was cursory and fairly one sided. When I asked about physical therapy he said I shouldn’t need it. Though I don’t have major issues at present and am inclined to be a do-it-yourself type of person, I have several questions and am intent on optimizing my recovery and returning to as full function as possible.
At almost three weeks post surgery, my major concern is with returning to the neutral spine stability exercises, such as planks, bird dog and gluteal bridges. Is it safe to return to these now, or do I need to wait until six weeks out as the surgeon recommended? I’m not sure he understood exactly what I meant when I asked about return to exercise. I had hoped to return to work after six weeks (construction, light duty initially) but I’m doubtful I will be able to if I haven’t begun some rehab.
My second concern is with a minor injury that occurred weeks prior to my surgery that I haven’t yet been able to resolve. Upon rising from my back on the couch with my ~30 pound son on my chest in somewhat of a twisting motion I heard a loud pop/crack in my spine that was somewhat painful. In the days following I had some radiculopathy in the L1 dermatome, at the top of the hip bone and into the inguinal area. This thankfully resolved within a week, but point tenderness remains in the T12-L2ish area, and I notice it particularly when extending my spine. Could there be a stuck facet joint or two that could be relived by manual manipulation? How soon might I seek the services of a chiropractor? Would it be safer to use the activator tool as opposed to traditional manipulation? Finally, what role might the denervation of the left side multifidus and subsequent atrophy play in the malignment of the spine at that level or elsewhere? Could I also be noticing the effects of new load on the facets due to mechanical changes from the discectomy, especially given that I’m walking much more now?
I sense that a sooner rather than later return to back strengthening exercises will behoove my recovery and I am eager to have this somewhat painful mid spine issue resolved. I seek your advisement in pursuing the correct timetable and modalities for the resolution of these issues. Thank you.
Your post-operative care unfortunately is not that unusual as there are some surgeons who “don’t want to know you” after surgery. In this case, you can use your family doctor to help with rehab. Start on some non-movement core exercise initially after surgery and allow the physical therapist to slowly increase load and motion to your spine. This therapist should be able to guide you to a strong core. You should also review this thread to understand what the biomechanics of the spine (rules of the road) to prevent a future hernation. (“https://neckandback.com/treatments/conservative-treatment-mechanical-lower-back-disorders/”).
Activator is safer that traditional chiropractic manipulation immediately after surgery and I would wait at least 12 weeks after a microdisectomy to consider adjustments.
Why would you consider denervation of the multifidus?
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.Thank you Dr., I appreciate your reply.
I will pursue a referral to a qualified Physical Therapist who is hopefully experienced in back rehab. My flexibility I think is particularly limited, as it was prior to my injury and has only gotten worse since I’ve been limiting my motion for almost seven months now. My core strength I think is fairly good and my BMI very low (5’9”, 125lbs). I intend to take my rehab slowly, but I wonder if I’ll gain the confidence to return to my physically demanding job as a carpenter. My surgeon described my annular defect as “fairly large” and the HNP as “huge”. I think I had two or possibly three episodes of herniation once the initial defect occurred.
My concern with the multifidus arises because it has been a persistent tender spot since the initial injury. Prior to the full height of the radicular symptoms, I had thought my issues had been resolved after a few trips to the chiropractor, and I ventured on a family vacation that required an ~11 hour car ride. While applying sunscreen to the low back a few days into the vacation I felt the extremely tender spot right along the spine on the left and I knew something wasn’t right. Thirty minutes into the return trip I got a searing pain in my left hip that I could not resolve positionally and basically everything was downhill from there. I did continue to work the next two months, including two hours commuting each day, but this eventually became too much.
While I did learn to identify muscles innervated by S1 in the leg, it was a while before I realized that the multifidi are innervated by dorsal rami of nerve roots in the lumber plexus. I’m not certain I have my terminology correct, and this underscores my inexpert understanding of this complicated topic. In the course of receiving two ESI’s my physiatrist asked about tender, painful spots in my back and was able to put her thumb directly into it, eliciting a jump. On the second shot I believe she even injected some steroid intramuscularly, as it felt different from the first shot. It did seem to help with the tenderness, which hasn’t been as bad since then, and seems to have improved post surgically.
What concerns me most, in addition to my apprehensions about returning to my work, is the rehabilitation of that small muscle and the small deep hip flexors. I read one study that indicated that atrophy of the multifidus was radiographically evident in as little as a few months. I also understand that it can be difficult to isolate in exercise and rehab. I’m also concerned with the relatively small amount of muscle mass I have to “give” to atrophy/weakness given my body size.
This process has changed my outlook on the future and I am in the process of accepting the new limits that are on my body. There is after all a lot to live for and I have many reasons for which to be thankful. That said, I am eager to do all that I can return to as full of function as possible, for myself and my family, while also limiting the possibility of the recurrence of this type of injury. I do believe that knowledge is a key part of insuring this process goes as smoothly and successfully as possible, so I hope you will forgive me being long winded.
Local tenderness is a poor indicator of pathology. Many times, this tenderness has nothing to do with the disorder.
These “trigger points” can be totally independent of the pathology but as you have found out, local injection can yield some relief.
Multifidi muscles cannot develop the force necessary to stabilize the spine as the forces that move one vertebral body are at least 7 times greater than the multifidi muscle can generate. Don’t focus too much on this small group of muscles.
The disc herniation came from a tear of the back wall of the disc. Since the disc is avascular (no blood supply), this tear will never heal-leading to the question, “what are the odds of another disc herniation occurring”? The answer is 10% in an active population.
Read the section on spine biomechanics to fully understand what you should and should not subject yourself to. (https://neckandback.com/treatments/conservative-treatment-mechanical-lower-back-disorders/).
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.I have found your section on spine biomechanics as thoroughgoing a primer as I have seen. Above all it demonstrates an empathy toward patients that is refreshing and encouraging. Thank you for your help.
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