[tjfisher]

#20662

Dr Corenman

I am a 55 yr old male. I am very fit and have never smoked. I had a laminectomy for L5/S1 disk herniation 1 year ago. I still have fairly significant Sciatica pain. I had a post-op MRI and it does not show any impingement. My neurosurgeon has basically disowned me. His statement is “the S1 nerve is damaged and it might or might not heal over time”. I have gone to a Pain Management clinic and their guidance is for me to accept my situation and use Gabapentin and Tramadol to get by in life. I have 2 questions:
1. How hard should I pursue a solution vs accepting my situation? My inclination is to never stop pursuing a solution.
2. Assuming I do not find a solution is it your experience that patients like me with chronic post-op pain live with this forever? I could handle this better if I thought that there is fairly decent hope that my body will adjust/heal over time. Even if that time is 2-3 years that is much better than forever. Do some people eventually get better?

Thank you

[Donald Corenman, MD, DC]

#20665

First-do you have more leg pain standing and walking or sitting? Sitting pain is typically associated with a disc hernation and standing with lateral recess or foraminal stenosis. This makes a difference when interpreting the MRI findings and X-rays which should include flexion and extension views.

There are times that the surgeon and radiologist might misinterpret images so another set of eyes (a second opinion) would be something to consider.

Interestingly, I just took care of a pro skier who had a prior disc hernation 1 1/2 year ago with a successful microdisectomy and great relief of leg pain at that time. He had acute onset of new but recurrent leg pain (same leg pain as from the prior herniation but with a year of no pain in-between episodes). The MRI noted no evidence of new herniation but just the typical “scar” tissue.

He acted just like a new disc herniation with all the typical symptoms and exam findings. I told him I would surgically neurolyse the nerve (free it from any adhesions which can sometimes fix the nerve in place and generate pain). Much to my surprise, when I freed up the nerve root, there was a relatively large disc hernation sequestered under this root. I removed it and the patient had 100% relief of his leg pain and is back to professional skiing.

I normally “believe” the MRI but I went back to this imaging study and reviewed it with my radiologist. We both agreed that there was no obvious disc herniation so great care needs to be taken when reviewing all the data (including patient history, examination and imaging.

If you have pain with standing and walking, this is a different but related problem. The disc can collapse after a hernation and narrow the foramen or the lateral recess (see the website to understand these conditions). Pain will be generated by standing and walking and be relieved with sitting or lying down.

If both situations are disproved so there is no mechanical compression of the nerve ether with standing or sitting, you certainly could have chronic radiculopathy (nerve injury that might not heal). There are medications and implants that can be considered (spinal cord stimulators or peripheral nerve stimulators).

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.

[tjfisher]

#20670

Thank You for the reply.

Walking is ok, standing does not elevate my pain unless if standing for a long period of time. Sitting always elevates my pain. There is no position that I can contort my body that will bring on instantaneous acute pain. I have found it very difficult to correlate activity to pain. The only exercise I know for sure will result in pain that will last for days/weeks is squats (3 sets of 15 with no weight, did not hurt while I was doing them though).

My sciatica symptoms (I have little to no lower back pain unless you include tailbone area)
-mainly right leg but left as well
-some weakness in right leg (heel raises are about 75%)
-buttock, groin, tailbone, underside of thigh, calf
-stabbing, burning, aching, cramping of thighs/calfs
-numbness in bottom of right foot

1. Does this provide any more insight?
2. Does the eventual pain brought on by squats provide any unique clues?
2. Are you aware of “stand-up mri”? I just found it on the web. It can apparently scan in any position. Looks like there are a few locations around the country.

Thank You again.

[Donald Corenman, MD, DC]

#20672

You have classic symptoms of an S1 radiculopathy. The fact that there is no activity that consistently will aggregate your pain could yield some evidence of the presence of a chronic and not of compressive radiculopathy.

The stand-up MRI is not worth the time and money as their images are poor and generally unhelpful.

Delayed onset leg pain with squatting maneuvers does not differentiate the diagnosis of compression vs. chronic injury.

You could consider a CT myelogram to have another tool to visualize your nerve root. It can help with diagnosing the cause of the nerve irritation.

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.

[tjfisher]

#20687

Once again – Thank you for your responses

I will pursue all of the diagnostics you have mentioned. Following that it sounds like I may be faced with accepting a chronic condition. I consider myself an athlete and have hoped that my conditioning would give me an edge adapting to the situation. I guess I’m looking for words of encouragement.

1. Can this change for the better over time (1yr since surgery)?
2. Do you see athletic type people with chronic Sciatica – do they cope in a manner that provides for a quality of life?
3. Any tips as to how to cope?

Thank You

[Donald Corenman, MD, DC]

#20688

Unfortunately, physical conditioning does not bare any weight or chronic nerve root injury.

Yes, over time this condition can improve but by small increments.

Coping with this chronic pain is interestingly, both more and less difficult for an athlete. Athletes are conditioned to ignore pain so they are generally more pain tolerant. However, activity that stretches the nerve root (most athletic activities) will trigger more pain.

I would make sure there are no adhesions or compression based upon the MRI (with the caveat noted above). If there are no indications to explore the root surgically, then management is necessary. This includes medication (see this section on the website) which involves membrane stabilizers and NSAIDs.

Finally, a spinal cord stimulator or peripheral nerve stimulator can be considered the “final” treatment pathway if nothing else is effective to reduce pain.

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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