ol99ParticipantMarch 17, 2021 at 1:35 amPost count: 14
I was reading the surgery indications article (https://neckandback.com/treatments/when-to-have-surgery/). Awesome stuff, though I have a question.
I don’t have a huge back problem – I have a single bad segment (L5S1) with a broad-based protrusion, annular tear, lost signal, lost height, and instability. All other segments are OK.
My instability is 1mm retrolisthesis when lying down, and grade I anterolisthesis in extension.
I’ve adjusted my life so that I have almost no pain, and I can walk and do office work. My issue is gait problems and lack of mobility. All issues started after a bad lift while training.
– I can’t go fast or run because I have a limp because of foraminal stenosis blocking nerve movement, I get pain going uphill or downhill. I can’t carry more than 8 lbs without developing bilateral calf spasms. I can’t sit on chairs where my hip is below the knees and I can’t stand still for more than a few minutes. I can’t lie down with straight legs and have to keep a bend in my back to sleep.
To sum up, I can’t do flexion or sit down too long because of the disc and I can’t do extension or stand because of spondylolisthesis, limiting any light sport activity. I used to hike about two times per week previously.
I’m 32 M and the doctors and EMG say I shouldn’t be at any risk for nerve damage. I don’t want to be greedy and get surgery just to maybe get better – since I can still function at about 30% of before my injury, and I could get worse with surgery.
We’re expecting a baby this year and I’m worried about how limited I’ll be in that regard.
I guess in a way I meet a part of the indications for surgery from the article, but I don’t know whether my situation is common and whether people that have a case like mine get better in the long-term with surgery?
I’m scared if I need to have two more fusions by the time I get to 60-70 and then I would have to spend my retirement days in constant pain… Is it even possible or advised to get ADR above a fused level?
Do you have experience with cases like this and what would a usual route be? Would there be value in stopping my instability before it gets to Grade II and beyond (or maybe this doesn’t progress)?
P.S. This has been going on for 9 months – previously I only had mild occasional back pain for about 15 years (since high school). I’d say I get a 1-2% improvement per month in functionality. I did 3x PT and do all the proper spine sparing lifting techniques. I walk a few miles every day and limit sitting time to ~1 hour with breaks.ol99ParticipantMarch 17, 2021 at 2:21 amPost count: 14
Also to add in case it helps in determining my options – perhaps my gait issue is due to muscle weakness with the S1/L5 nerves, since I do get an occasional foot slap while walking.
Two months ago I had fall while climbing stairs and hit my knee possibly causing injury since I still have pain. The doctors said to get a knee MRI if it doesn’t go away next month.Donald Corenman, MD, DCModeratorMarch 21, 2021 at 10:27 amPost count: 8465
“I don’t have a huge back problem – I have a single bad segment (L5S1) with a broad-based protrusion, annular tear, lost signal, lost height, and instability. All other segments are OK.
My instability is 1mm retrolisthesis when lying down, and grade I anterolisthesis in extension”.
You have an instability of the segment at L5-S1 if you go from a retrolisthesis (backwards position slip) to a grade one (3-7mm) forward slip. This can be quite painful.
You then note “I’ve adjusted my life so that I have almost no pain, and I can walk and do office work. My issue is gait problems and lack of mobility”.
Does your gait deficit and lack of mobility seem tolerable to you? If so and you have no significant motor weakness due to the L5-S1 level, then you don’t need surgery. If however, the impairment is more significant or motor weakness due to L5 nerve compression is present, you should consider surgery. In your case, L5 nerve compression could cause foot drop or gluteus medius weakness leading to a trendelenberg gait.See https://neckandback.com/conditions/walking-disorders-nerve-joint-injuries-change-gait/
Dr. Corenmanol99ParticipantMarch 21, 2021 at 3:24 pmPost count: 14
Interesting that you note the pain from switching between retrolisthesis and anterolisthesis. I’ve felt that type of pain but never knew that this was the reason why. I’ve had that kind of switching pain (when going from standing to lying down) ever since I was in high school, I guess that’s when I developed the pars defects.
I’m not really against surgery, some days I do think about scheduling it. I’m just scared of the unknowns.
What are the chances I get worse with surgery? Like for example, my gait issue doesn’t get resolved and I start having more pain?
Are there people that don’t have to get a second or third fusion? I’m 32, so worried I’ll get fused up to L2 or L3 by the time I’m 70.
And finally, is surgery easier and more successful if I stop my isthmic spondylolisthesis while it’s grade I? Can this progress to grade II or III? The doctors noted the slip has progressed over time.Donald Corenman, MD, DCModeratorMarch 21, 2021 at 5:46 pmPost count: 8465
The larger the grade of spondylolisthesis, the more difficult technically the surgery becomes. None-the-less, it is not an absolute that over time your slip will become larger. Your level is already unstable so a fusion should help you to the tune of about a 90% success for 3/4 relief of pain. In my opinion, whether you have surgery or not, the chance of the level above becoming a problem is 2.5% per year.
Dr. Corenmanol99ParticipantMarch 22, 2021 at 1:43 amPost count: 14
Thanks Dr. Corenman for explaining this stuff, it gives me a better picture of what to expect in the future. I will definitely post an update here in case I get a fusion.
One doctor mentioned injections – I once had a bilateral S1 interlaminar nerve block, which didn’t help with the leg pain from where my L5 is getting crushed. Does the injection need to be done differently for my condition? Like, would the L5 nerve need to be targeted in a transformational approach at L5S1, or directly in the root at L4L5?
Also, have a question about OLIF – I know you prefer TLIF, and I can go with that, but what does indirect decompression mean? Does that mean that a part of my protrusion might stay after the fusion? Or is the disc space completely cleared? I don’t have any extrusions or sequestration from the disc, apart from the annular tear. Other than that, I guess OLIF (with posterior fixation) might be too experimental still to try on an unstable segment?
Asking because I have one offer for a TLIF and another for an OLIF. I’d trust your judgment on this – would even come to your clinic but I’m too far away.
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