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  • Saleh
    Member
    Post count: 5

    Good Day Doctor,
    I’m writing to you and forgive me if i don’t sequence my things properly..
    My name is Saleh.
    192 cm, 108 Kg 32 yrs old. Handball Player.
    2nd week of March 2012:
    • I was feeling very minor pain in the Right lower back .. during training , i jumped using my R Foot and felt like knife cutting my internal thigh severe muscle strain .. but NO back pain at all whether moving or bending.
    • I put ice on injured thigh…..and next day along with the thigh pain I felt kind hardness in my R calf muscle with burn sensation in it, as well as back thigh / right hip. I was limping for 3 weeks..
    • Kept using relaxon/ voltec for pain relief a bit..
    2nd week of April 2012:
    I made MRI and the findings was:
    Technique: Multiplanar image acquisition was performed using various pulse sequences
    – Spinal curature is maintained.
    – Vertebral bodies show normal bone Marrow signal.
    – The intervertebral discs at d11-d12, l4-5 and l5s1 showed loss of normal bright.
    – T2w signal with partial reduction of disk height consistent with degeneration.
    – Evident l4-5 disc bulge compromising the ventral aspect of the thecal sac with evident bilateral neural foraminal compromise.
    – Area of abnormal signal related to Right antrolateral aspects of the thecal sac opposite L5-S1 disc extending cranially and caudally measuring roughly 2.8 x 1.4 cm in maximum craniocaudal and transverse diameters likely extruded discogenic material its seen compressing the right aspects of thecal sac, obliterating right lateral recess compressing preforminal nerve roots.
    – The spinal canal diameter appear within normal limits.
    – Vertebral appendages and facet articulation are normal
    – No abnormal pre or paravertebral soft tissue signal seen.
    Impression:
    – Degenerative disc disease L4-5 disc bulge.
    – Possibility of L5 S1 disc extrusion with migration of discogenic substance as described correlation with contrast study is advisable. (DONE the contrast)
    I was diagnosed with L5 S1 disc prulaps and went through microdiscectomy surgery End of May 2012.
    CURRENTLY:
    • severe pain improved after surgery but STILL There is NO PROGRESS weakness associated with R calf muscle pain
    • I feel that weakness due to muscle weakness but along with burn sensation i believe its due to neuropthic affect with pinched nerve as shown in MRI..
    • I feel tolerable pain during activities except during walking or jogging weakness in leg goes up.
    • Now feeling stable burn sensation and pulsation in top of heal, calf, back thigh. But very tolerable.
    • I can do my activity normally except try to speed up walk or jog ..
    • No skin color change.

    • the percentage of related pain in the back, buttock (66%) and leg 40% but leg weakness what is most bother me..

    Intensity of Pain
    Lower back 2/10
    Leg Buttocks 5/10
    • I didn’t notice any kind of improvement except the interior thigh pain..
    • Walking or jogging is pressurizing my calf muscle and i feel it goes weaker.
    • sitting that increases the burn sensation
    • I don’t feel much comfortable when sitting more than 15 mins and i’ve to adjust myself.
    • I can walk for an hour But with very regular speed.
    • Sitting longer increase the burn sensation.
    • Driving and computer work increase the burn sensation and it goes back and forth from buttocks back thigh, calf muscle down to heal.
    • No REAL back pain.
    • I can do everything including cross trainer, except jogging / running more than 10 meters, then the weakness starts.
    • Computer work is my daily activity. I rest for few mins every time i feel the burn sensation by doing quick stretching….

    Looking forward for your advice..

    Respectfully,

    Saleh

    cdlasnier
    Member
    Post count: 8

    Selah, it’s interesting you mention a “burning sensation”. I am 3 months post microdiscectomy l5/S1 and also sometimes have a burning sensation -it’s not painful just sometimes gets very hot in my back and a little in my buttocks but then goes away. It’s alarming and I hope nothing bad but interesting to hear I’m not alone! Hope you feel better soon.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    You have a classic history of a large extruded herniated disc at L5-S1 which compressed the S1 root. This root supplies the calf muscles (gastroc-soleus group). These muscles “push the foot down” when walking and running. A weakness of these muscles will cause a type of limp and make it difficult to run, hike and climb stairs.

    You underwent a microdiscectomy of L5-S1 and your pain improved but the motor weakness did not. You also have a “burning” pain residual in that leg. You notice increased weakness with prolonged walking and running.

    This is unfortunately typical for a chronic radiculopathy (see website). The nerve was injured by the large disc herniation and even though the herniation was surgically removed, the nerve has yet to recover. The burning sensation is typical for a nerve injury. The reason the leg becomes weaker with activity is that only a small portion of the muscle cells are firing in that muscle group. Most of the muscle cells are not getting the signal from the brain to contract and the ones that are still connected are too few to give a normal contraction.

    These working muscle cells fatigue easily as they are overloaded with work and cannot “keep up” with the load. This is why with continued exercise, the leg feels weaker.

    Muscle cells that are not connected to the brain are called “deinnervated”. These cells have a number of ways to recover but this takes time. Some of the recovery methods are budding (sprouting), functional recovery , nerve regeneration and muscle hypertrophy. Budding is a phenomenon where the deinnervated muscle cells puts out a neurochemotactic factor. This is a chemical “cry for help” and any close functioning nerve will bud or sprout a branch to connect with this muscle cell. This can take 12-16 weeks.

    The second recovery method is functional recovery. This is where the nerve itself that was damaged will heal which allows the signal to continue down the nerve. The functional block could be from damage to the insulation (myelin) or malfunction of the membrane of the nerve. Recovery should take place relatively quickly.

    The third recovery method is by axonal regeneration. If the nerve was severed but the insulation sheath (myelin) was left intact, the nerve can grow down this pathway. The nerve grows at about one inch per month. The problem with the S1 nerve is that it is the longest nerve in the body with some examples at 22 inches long. It could take many months for the nerve to grow down to the muscle in the leg (this is assuming the insulation sheath is still intact). If it takes longer than 12-18 months to reconnect with the muscle cells, these cells will atrophy and fibrose. This means that even if the nerve grows and reconnects, the muscle cells will be useless and not be able to contract.

    The last possibility for recovery is muscle hypertrophy. Arnold Schwarzenegger is what many individuals think of for muscle hypertrophy and that thought is not far off. The residual muscles can be conditioned to become stronger and last longer. Training is the key for this and this result may take three of more months of hard work to achieve success.

    Dr. Corenman

    Saleh
    Member
    Post count: 5

    Dear Dr. Corenman,

    Thank you for your explanation.

    I have done New MRI last week. kindly have me your thoughts about it.

    CLINICAL INDICATION:
    Post-lumbar decompression 5 months back, now complains of weakness in right lower limb.

    multiplanar multiecho imaging of lumbosacral spine is carried out with and without contrast according to departmental protocol.
    No previous imaging is available comparison.

    FINDINGS:
    There is evidence of right laminectomy at L4 and L5 levels consistent with previous history of decopressive surgery.
    There is normal alignment and durvature of lumbosacal spine.
    Vertebral body heights and signals are well preserved.
    Disk dehydration is identified at L4-L5 and L5-S1 levels.
    Diffuse posterior disk bulge is noted at L5-S1 level compressing the thecal sac and resulting in mild right lateral recess narrowing.
    Mild posterior disk bulge is noted at L4-L5 level causing indentation on thecal sac, however, no neural foraminal compromise or radicular compression seen at this level.
    Mild abnormal signals are identified in L4—L5 and L5-S1 disks posteriorly with enhancement on post-contrast imaging raising the possibility of focal discities.
    Enhancing granulation tissue is identified at laminectomy site extending into posterior spinal soft tissues.
    There is minimal intraspinal extension of this granulation tissue at lower L5 level without any significant thecal sac compression. No intraspinal fluid collection or abscess formation is seen.
    The rest of the disks show no significant protrusion or herniation.
    Conus medullaris terminates at its normal position.

    IMPRESSION:
    Status post partial laminectomy at L4 and L5 levels with postsurgical changes. Mild diffuse posterior disk bulges are noted at L4-L5 and L5-S1 levels with mild right lateral recess narrowing at L5-S1 level. No radicular compression seen on either side at these two levels.
    Focal abnormal signal with post-contrast enhancements identified involving L4-L5 and L5-S1 disks posteriorly rasing the possibility of focal discitis.
    Clinical correlation and follow-up are recommended.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    The MRI report indicates you had surgery at both the L4-5 level and the L5-S1 level. You have a residual bulge at L4-5 which is not unusual after a microdiscectomy. There is no bulge at the L5-S1 level. There is no recurrent herniation that the radiologist noted.

    You do have significant granulation tissue at the previous surgery sites. Granulation tissue can be “healing tissue formation” but also can indicate the possibility of an infection. There are non-virulent organisms (ones that don’t create too much of a body response) that can cause this. I don’t expect that you would have an infection but some labs might be in order. Ask you surgeon.

    If infection is ruled out, then you are correct that this is residual neuropathic pain and will take some time to hopefully fade away. I have found that epidural steroid injections can help to reduce the inflammation around the nerve root and speed up nerve recovery.

    Dr. Corenman

    smiley30
    Member
    Post count: 3

    Doctor,

    First time using this site and asking questions. I have had back pain off and on past year. It hurts in my lower back. There is no kidney infections and i have also had a bladder sling (2 times,first didn’t take.

    my back is hurting more,trouble sleeping and walking it pops alot. I still excercise alot.

    my xray for lumbar spine 4 views and lateral feexion and extension views

    radiologist reported as his inpression: possible muscle spasms,transitional vertebra at L5-S1 with partially lumbarized S1 segment.

    straightening of lordotic curvature.

    please in lamen terms explain what this is and if its important to follow up with doctor.. my back just hurts.. im 29 f almost 30..

    thanks

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