Dr. Corenman,
I hope that this catches your attention and hopefully you can comment on it. Will be a bit long to describe the entire situation though.
In 2005, at 35 years of age, I herniated L5-S1 weightlifting. Eventually had laminectomy in Houston which worked very well. No troubles since, ran half marathons etc.
In 2012, at 42 years of age, I herniated L4-L5, not really sure what caused it. Large herniation (about 1.2 cm), had microdiscectomy done by a neurosurgeon in PA. Healed but never worked as well as the L5-S1 disc surgery. Off and on low back pain which would go away with staying active and running. In fact, the surgeon told my wife post surgery in the recovery room that “he did the best he could and that there was a lot to clean up”.
In May of this year, the low back pain became much worse. An MRI in July showed another large herniation on L4-L5, 1.1 cm this time. The two large herniations on same disc have reduced the disc height to about 4-5 mm at the narrowest point. My symptoms are 90% low back pain, some sciatica which can go both to calf muscle and the big toe on right leg (so probably both L4-L5 and L5-S1 dermatome are involved).
I went and saw the neurosurgeon who did my 2005 laminectomy in Houston to see what he recommends. This gentleman is one of the best in my area, has tons of experience, has good surgical history with me and is an honest, straight shooter.
His answer, the L4-L5 reherniation means that another surgery is inevitable given the severe spinal stenosis. The size of herniation, low height of the disc, facet hypertrophy being seen on MRI, previous history of poor microdiscectomy on that disc means he would not even consider another microdiscectomy on that disc. He thinks that there is high risk of nerve damage trying to clear up everything, and it would merely delay the inevitable fusion given all other issues in that area.
His recommendation: L4-L5 fusion. Given the disc below has also been operated on, he recommended also fusing L5-S1. All disks above L4-L5 look nice and healthy.
I do have another neurosurgeon who thinks he can do another microdiscectomy. I do not know this guy, though he is highly rated. I look at the imagery and wonder if that merely delays the inevitable. Maybe I should use my age (47, still on youngish side), little loss of muscle strength etc to heal better after fusion as opposed to trying everything till things get worse. I have tried physio but have had little in preventing surgery in the past. Given the large herniations I am prone to, not sure physio can help with those.
There is also the question of trusting your surgeon. If I will ever get a fusion, my 2005 surgeon would be the guy to do it. He has been consistent in his opinion. When my insurance balked at the fusion on L5-S1, he went to bat for me and won the appeal. I am scheduled for surgery next week. Given my doubts, he also worked to arrange a second opinion with another highly rated neurosurgeon – who is not part of his practice – in my area. I am seeing this gentleman early next week for one last opinion.
What would you recommend? Is it time to get the two level fusion and join the Borg collective? Would you consider another microdiscectomy? I know you generally recommend doing it twice before fusion, but I see the rather thin disc, massive herniations, the facet joint issues etc and wonder if that is the right answer here.
