[metallikat]

#32726

Hi Dr. Corenman,

Thanks for your time. I also really appreciate that you are both a surgeon and a chiropractor. A lot of surgeons seem too black and white about chiropractic. I am 6 months post microdiscectomy at L5-S1. MRI before surgery findings said, among other things:

“Straightening of the lumbar spine. No spondylolisthesis”

“L5-S1: Disc desiccation with loss of disc height. Large right subarticular disc extrusion measuring 11mm AP. Complete effacement of the right lateral recess with impingement on the traversing right S1 nerve root. Mild central spinal stenosis with AP thecal sac diameter of 8mm. No significant foraminal stenosis.”

Impression said:

“1. At L5-S1, large right subarticular disc extrusion with impingement on the traversing right S1 nerve root.
2. Facet arthropathy at L4-L5 with mild bilateral foraminal stenosis.”

I had tried conservative management for 4 months prior to the surgery. This involved traction and electroacupuncture. Unfortunately, I felt using the Teeter Dex II and also the Nubax back stretcher both aggravated the problem. In-office traction at chiropractor was okay though.

I was totally bedridden for 10 days pre-surgery with symptoms on right side and was admitted from the ER to go in for surgery. For the first three months after surgery I was recovering well. The weakness in the right leg improved and I thought at this rate it would make a full recovery. Nerves were sensitive to extension on both sides (even though I had no issue on left side before surgery), but it improved with time. Antalgia (body deflected to the side) resolved. I could stand, walk, sit, and lie down again, all without much pain. I worked up to walking 2 miles briskly on a dirt track every day. I would face my back to a corner of the kitchen counters and lift myself off the ground with my arms to put some traction on the low back. I never had an issue with this.

Then around 3 months post surgery, I did the same dangling from the kitchen counter, but this time facing towards the counter corner. This for some reason irritated the nerve and residual symptoms kicked up a notch, and some new ones appeared. I had more reduced sensation on the outside of the right foot, but now I also had emergence of reduced sensation on the middle three toes of the right foot. This confused me as I thought those toes were not associated with the level I was operated on. I also had emergence of reduced sensation on the heel of left foot, which I never had before at any time. Things seemed stable at this new level of symptoms. Then when COVID lockdown began, exercise reduced and I started pacing in my garden for half an hour, instead of briskly walking on the public track. Now the last 1 month all my residual symptoms have gradually intensified for no apparent reason, and weakness is increasing in both legs, especially the right calf, which was always the most afflicted. But I never had weakness of left side at all before now. Nor burning. Lying on my back with my knees up, reclining on a wedge pillow causes symptoms, when before 1 month ago it would not.

I have avoided sitting ever since surgery and am pretty much either using a standing desk, or reclining on my wedge pillow on my bed.

Questions:
1. What kind of doctor do I need to see? Do I need another MRI? Would this probably just be called failed back surgery and lead to symptom management? My neurosurgeon is still closed due to COVID and I can’t consult him.
2. What could be a reason for symptoms appearing on left side after the surgery? And why would progressive weakness occur recently? I don’t really even have that much pain, so it is surprising that weakness would start showing up.
3. I have read clinical trials and case studies of discs being regenerated through multimodal chiropractic things. I have also seen surgical literature showing regeneration of discs occurring spontaneously after surgically correcting flat back syndrome. Do you think it is worth pursuing chiropractic attempts to regenerate disc through things like traction and restoring lordosis though molding with tools like a denneroll? I feel like the mechanics of a flat back are just plain bad for sciatica and discs. Is there still enough material in the nucleus and the annulus left to be rehydrated after having lost some of it through discectomy?
4. Do you have any experience with PEA (palmitoylethanolamide) for sciatica or failed back surgery syndrome? There is very impressive literature on it that is almost too good to believe. Any experience with either methylene blue or ozone epidural injections for sciatica?
5. Though I consider ozone to be more conservative than steroids, is this the kind of situation that steroid epidural injections may help with? I am not looking for symptom management, but actually stopping the disease process.
6. I took 1 month of fibrinolytic enzymes (lumbrokinase, serrapeptase, and nattokinse) recently for unrelated reasons. They in theory could dissolve scar tissue. Is there any theoretical reason why doing so might have affected the disc or surrounding region?
7. I have a lot of tightness and some cramping on the right side since waking up from surgery. It has somewhat improved with stretching, walking, and graston therapy. Is this normal?
8. Can the symptoms in the middle three toes of the right foot be explained by the given history despite not being on the relevant dermatome?
9. My scar is about 1.5 inches. I probably still have the spinous process itself, right? Just part of the lamina would have been drilled out, right? That is technically a laminotomy, and not a laminectomy, right?
10. Is the ligamentum flavum really vestigial? It seems so substantial. I wonder if it becomes important if the spinous process is removed?
11. What happens to the attachments that are removed when a laminectomy removes the spinous process? Are there just “unanchored” living muscles and ligaments floating around in people’s back. I can find zero mention of what these particular muscles or ligaments are even called. My dad has had 4 laminectomies and I wonder how unstable things become.

Thanks so much for your time. I am very inquisitive (and worried). I hope it is not too much.
Thanks,
David

[Donald Corenman, MD, DC]

#32727

You note that; “3 months post surgery, I did the same dangling from the kitchen counter, but this time facing towards the counter corner. This for some reason irritated the nerve and residual symptoms kicked up a notch, and some new ones appeared. I had more reduced sensation on the outside of the right foot, but now I also had emergence of reduced sensation on the middle three toes of the right foot. This confused me as I thought those toes were not associated with the level I was operated on. I also had emergence of reduced sensation on the heel of left foot, which I never had before at any time”…”Now the last 1 month all my residual symptoms have gradually intensified for no apparent reason, and weakness is increasing in both legs, especially the right calf, which was always the most afflicted. But I never had weakness of left side at all before now”.

With new onset of weakness, yes you need a new MRI. Weakness is always the triggering symptom that needs immediate attention. You would need to see your spine surgeon after the new MRI and I suspect if you call his office with your new symptoms, he or she would order the images without question.

The symptoms could be from a new herniation, and possibly this herniation now crosses midline. You can look at any other treatment if your examination does not indicate true weakness but with progressive weakness, get into your surgeon’s office now.

Most likely you had a laminotomy. Yes the ligamentum flavum is vestigial. I commonly joke about developing a new product “Flavaway” that would cure most stenosis cases as the ligament hypertrophies when we age commonly causes spinal stenosis.

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.

[metallikat]

#32732

Thank you. My PCP was able to order an MRI with the help of your comments. If something shows, he will refer me to a neurosurgeon that is open during the lockdown. Otherwise I think he wants to refer me to a neurologist.

[Donald Corenman, MD, DC]

#32737

Excellent. Please keep the forum informed of your progress.

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.

[metallikat]

#32743

Hello Dr. Corenman,

New MRI came back. It says among other things:
“Disc desiccation and mild loss of disc height ta L5-S1.” [Note the word “mild”]
“L4-L5: No evidence of […] neuroforaminal stenosis.”
“L5-S1: Broad-based disc protrusion measure 5mm without significant central canal stenosis. Previously seen right subarticular disc extrusion has resolved. No significant foraminal stenosis.”
“Impression: Broad-based disc protrusion measure 5mm without significant central canal stenosis. Previously seen right subarticular disc extrusion has resolved. No significant foraminal stenosis.”

Previous MRI before surgery said:
“Disc desiccation with loss of disc height.” [Note the absence of the word “mild”]
“L4-L5: […] Mild bilateral foraminal stenosis”
“L5-S1: Disc desiccation with loss of disc height. Large right subarticular disc extrusion measuring 11mm AP. Complete effacement of the right lateral recess with impingement on the traversing right S1 nerve root. Mild central spinal stenosis with AP thecal sac diameter of 8mm. No significant foraminal stenosis.”
“Impression:
1. At L5-S1, large right subarticular disc extrusion with impingement on the traversing right S1 nerve root.
2. Facet arthropathy at L4-L5 with mild bilateral foraminal stenosis.”

Comments/Questions:
1. I am getting referrals to a neurosurgeon and a neurologist
2. It is my hope that the surgeon might be able to see on the MRIs if the disc height increased slightly due to traction, etc that was done for some weeks prior to surgery.
3. The new MRI does not note the mild foraminal stenosis that the old MRI did at L4-L5. Is that something that could have gone away with traction and mobility exercises?
4. The new MRI did not note the mild central stenosis with AP sac diameter of 8mm. Nor did the old MRI clearly explain what the source of that stenosis was? Any clue? Was the “hose” just narrow for no reason? And could it really have resolved since the last MRI?
5. The new MRI says protrusion does not cause “significant” stenosis. I take it this is not the same thing as “zero” stenosis. And I read that even without actual contact with the dura, protrusions can cause inflammation in the area, causing nerve symptoms. Given my new bilateral symptoms including weakness, does this protrusion look like the probable cause?
6. Any chance a surgery would allow me to keep the spinous process, and just get away with maybe having another laminotomy on the other side as well?
7. Any chance of treating this with traction?
8. If hernia retracts with traction, would the annulus heal itself over?
9. Is there time to mess around with such alternatives, or given the weakness symptoms should I just get surgery in your opinion? No one would know I have weakness by looking at my gait.
10. Since right after the first surgery, extension of both legs would cause nerve symptoms. Does that make sense anatomically given I presumably did not have this protrusion at that time, but only had the extrusion on one side? What explains it? Inflammation/irritation in the general region caused by the surgery?

Thanks,
David

[metallikat]

#32744

ALso, does “protrusion” mean the annulus is still in tact and nothing has actually leaked out?

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