Increased Back Pain After L4-L5 Microdiscectomy with ReHerniation

///Increased Back Pain After L4-L5 Microdiscectomy with ReHerniation
Increased Back Pain After L4-L5 Microdiscectomy with ReHerniation
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  • AvatarLC_IN_NYC
    Participant
    Post count: 4

    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?

    AvatarDonald Corenman, MD, DC
    Moderator
    Post count: 6840

    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.
    AvatarLC_IN_NYC
    Participant
    Post count: 4

    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

    AvatarDonald Corenman, MD, DC
    Moderator
    Post count: 6840

    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.
    AvatarLC_IN_NYC
    Participant
    Post count: 4

    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

    AvatarDonald Corenman, MD, DC
    Moderator
    Post count: 6840

    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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