Increased Back Pain After L4-L5 Microdiscectomy with ReHerniation

Tagged: herniated disc, nerve compression, neurologic deficit, radiculopathy, tailbone pain

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LC_IN_NYC
Participant

August 10, 2019 at 11:25 pm

Post count: 16

#30842

Dear Dr Corenman,

I write in the hopes of receiving new insight regarding the onset of severe low back and moderate sciatic pain nearly four weeks after surgery. I am an active 31 y/on female who only had mild to moderate low back pain until late June when a large herniated lumbar disc caused by a cough essentially stopped my life in its tracks.

In mid-July, I had an urgent laminatomy with microdiscectomy that removed a 5cm disc fragment at L4-L5 level. The disc herniation had caused severe numbness and weakness in my left leg that was significantly relieved when the nerve decompressed, though I am still at 60%. However, I officially reherniated 2.5 weeks post-op and my pain has now worsened with radiating tailbone pain, low back pain, and sciatic twinges in both legs though the left is worse. I had until now been bothered only by sciatic leg pain. The new MRI summary was “Recurrent disc herniation at L4-5 with left greater than right lateral recess stenosis and severe canal stenosis. Small postoperative fluid collection at the left L4-5 laminotomy.”

I am currently on my second Medrol Pack since the reherniation and having little to no relief. The pain is significant even while lying down, completely unaffected by flexeril or acetaminophen. This pain increase may have been caused by increased sitting as I had been improving somewhat prior to a few necessary car rides (reclined with breaks). However, apart from the surgery itself and initial herniation, I have not had low back pain this severe and was managing quite well with ibuprofen and Tylenol.

Could all of this increased low back and tailbone pain be caused by the herniated disc, or is it a new problem like pudendal neuropathy or the fluid collected? My surgeon only noted the reherniation when going over the results. My other big question is about my likelihood in terms of healing this disc on my own vs with revision surgery. My understanding is both have poor outcomes and I am worried that due to the size of the annular tear I will only reherniate again after a new surgery. My surgeon thinks I am too young for a fusion and we have not discussed replacement or annular closure (which I am curious about).m

I appreciate your insights and hope you can help shine a light on this situation. The pain is keeping me from my life and career, and causing a great deal of sadness. Is all I need rest, or is there anything more I could do to improve my chances of recovery?

Donald Corenman, MD, DC
Moderator

August 11, 2019 at 10:50 am

Post count: 8660

#30849

In my opinion, you need another microdiscectomy now. You note; “my pain has now worsened with radiating tailbone pain, low back pain, and sciatic twinges in both legs though the left is worse”. Your MRI report is concerning “Recurrent disc herniation at L4-5 with left greater than right lateral recess stenosis and severe canal stenosis” The term “severe” means that the spinal canal is full of herniation material and is compressing the entire caudal equina (large group of nerves that pass through this area).

Another decompression surgery is what is required now as long as there is no instability (unlikely at your age). Trying to treat this without surgery is most likely not to be successful and with severe compression, there is a possibility of some permanent damage. As your surgeon for surgery now.

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.

LC_IN_NYC
Participant

August 11, 2019 at 11:13 am

Post count: 16

#30852

Hi Dr Corenman,

Thank you. My spine surgeon is out this week and I have a follow up next Wednesday, August 21 (10 days) Can this wait or should I go to the ER at my spine hospital?

The last time I spoke with my surgeon the pain was not impeding me, which is why he took the wait and see approach, but I am afraid with increased sitting and movement I have significantly worsened things. My low back and tailbone pain has subsided a small amount overnight with rest since my first post and I haven’t had any increased muscle weakness, but I am still in a great deal of pain that is only relieved by icing.

Please let me know your thoughts if you can, I am terrified of losing my mobility because I am waiting for someone to return from vacation.

Best,
Lori

Donald Corenman, MD, DC
Moderator

August 11, 2019 at 6:05 pm

Post count: 8660

#30861

I think that there is a small but not insignificant risk to wait 10 days (and then another 3-10 days to schedule another surgery). If you trust your surgeon and want to stay with them, he or she should have a mid-level provider (NP or PA) who you could talk to tomorrow. If you are only so-so with your surgeon, an ER visit would 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.

LC_IN_NYC
Participant

August 11, 2019 at 6:55 pm

Post count: 16

#30864

Dear Dr Corenman,

Thank you for this response. I appreciate your advice during this difficult time. It sounds like we are on the same page, and if you have time, I’d value your thoughts on the below:

Today I was able to speak with a PA using my hospital’s urgent care line, and he spoke with my surgeon. The PA prescribed 300mg Gabapentin at my surgeon’s rec; the first dose has helped with sciatic pain but the low back and tailbone pain is still felt.

My surgeon also offered to put me on the schedule for August 22nd, a day after our follow up. He thinks that 10 days should not make a difference in terms of damage based on his last physical assessment and my symptoms, because my weakness isn’t increasing. The PA also said that I could come into the ER at my Spine Hospital for an assessment and new MRI if my condition worsens. He noted that the surgery could be pushed up it needed, but with revision surgery it is best to have someone familiar with my case.

With that, I am torn as to how to move forward. So my questions are (1) Would you advise seeking a second opinion from another surgeon in the meantime, rather than a visit to the ER and potential rushed surgery? I am very nervous about the risks of revision microdiscectomy, including another repeat herniation and need for fusion at my young age. The annular tear is quite large — the first surgery removed a 5cm, intact, disc fragment. And (2) With this in mind, should I be discussing annuloplasty or any other procedures with my care team?

I just want to ensure that I am taking the best path forward to avoid reinjury, particularly as I have another bulging disc at L5 S1 and mild degeneration at L3 L4. Until June, I had a full life and I also have been on disability from what is essentially my dream job (administrative and desk based, but active with local metro travel and events), fearing that I may never be able to return.

Thank you again for your time, this forum is a really wonderful resource.

Best,
LC in NYC

Donald Corenman, MD, DC
Moderator

August 17, 2019 at 9:40 am

Post count: 8660

#30898

If you are not progressing in your weakness (the weakness is stable and no worse), there is only a small risk for waiting. There are many practices that will not get you into surgery in under two weeks so I think your situation is satisfactory. You should be able to return to work after 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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Donald Corenman, MD, DC

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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