[Donald Corenman, MD, DC]

#9636

I think that high activity right after a microdisc surgery causes the root to become more inflamed due to healing inflammation. Every part of the body that has an injury will heal by the inflammatory response. This causes white blood cells to migrate into the injured area (and by the way-surgery is an injury that heals). These cells degranulate (release enzymes) that dissolve dead tissue. You want the healing response to be as minimal as possible as the nerve will be inflamed from the herniation and the retraction too.

Too much activity will move the nerve root and increase the inflammatory response. After about 10 days to three weeks, the inflammatory response will diminish and activity can increase. That is why I wait about 10 days before I start therapy and my therapists are trained to not push too hard in the first three weeks and to back off if the nerve complains.

There are no “sure-fire” signs that the disc has reherniated. I expect significant relief from the surgery but there are some nerves that were so inflamed prior to surgery that it might take three weeks to have them calm down. Also, there will be a seroma that forms from surgery (a pocket of fluid that slowly resorbs away). Activity can increase this seroma and it is a matter of time before it disappears.

The laminotomy bone removal is really not painful. It is the muscle retraction and nerve inflammation that is painful. Any time you retract muscles, this is uncomfortable and the back takes time to reintegrate these muscles. Anesthesia also causes tiredness that takes some time to resolve.

The annulus does develop a scar in the outer 1/3 due to some minimal penetration of blood vessels on the outside of the disc wall. The PLL will also scar and create a barrier to reherniation.

The nerve does not “de-inflame” right away but goes through the normal inflammatory process which takes plus or minus two weeks.

The space between the lamina is not big enough to expose the disc space for a microdisc. This opening is further away from the disc space the higher you go in the spine which requires a larger laminotomy (surgical bone window) with ascending levels.

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.

[radiculopathous]

#9638

Do you have any idea how wonderful for a distressed patient to be able to obtain this level of information detail, Dr. Corenman? You are really helping me understand this process and it gives me hope and better habits to treat my back during recovery.

With all my heart, thank you so much for taking the time to respond.

[Donald Corenman, MD, DC]

#9642

Thank You

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.

[radiculopathous]

#9731

Dear Dr. Corenman,

I’ve stumbled upon some data about recovery rates, I thought
I’d share this with you here as it adds a bit of detail to a
prognosis for nerve damage recovery.

This paper has some quantitative data on the nerve recovery
process post microdiscectomy:

“Recovery of muscle strength after microdiscectomy for lumbar
disc herniation: a prospective cohort study with 1-year
follow-up” (Gregor Lonne et al., 2011)

(Sorry I can’t put the URL in here your web forum software
doesn’t allow it. Search it on Google, easy to find full PDF
text for free.)

Executive summary:

– 1 year out, 75% of patients recover fully; 15% partially, and
10% not at all.

– The only predictive factor found was the intensity of the
“paresis”, based on “Daniels and Worthingham’s” method (I’m a
grade 4, 50% weak (or le.

– Pre-op duration of paresis was NOT significant (though their
median was pretty low at 6 days, these Norwegians operate
quickly I presume, and they admit to a low sample size)

Selected quotes:

“This study shows that 75% of the patients with limb paresis
due to herniated lumbar disc had full recovery 12 months
after micro discectomy. Patients with mild paresis can be
informed that they have a good chance to recover (84%).
Patients with severe paresis have less, but still a good
chance to recover (55%). Fifteen percent had some improvement
but not complete remission, and 10% had no improvement. The
recovery rate was similar to the results published earlier
[2, 6, 19, 20]. Previous studies evaluating more severe
paresis (grade 3 or worse) show similar associations between
the severity of paresis and the recovery rate [5, 7, 21].”

[..]

“Only the severity of the paresis was identified as an
independent risk factor for non-recovery. Surprisingly, there
was no association between the preoperative duration of the
muscle weakness and recovery, and we could not identify any
cut-off in duration of paresis that would indicate a good or
poor prognosis for recovery. This is an important finding
which does not support the concept that the best effect of
surgery is obtained in patients with short duration of
paresis. The size of our sample might, however, have an
impact upon this finding. We did not look at patients with
paresis less than 24-h duration, since duration of paresis in
this study was difficult to define in terms of hours.”

[Donald Corenman, MD, DC]

#9802

This is a good study and generally follows what I have observed. It also generally follows the gathered data to this point in my study. Patients with dense weakness (graded 4- or below on a 0-5 scale) seem to have worse outcomes.

The questions not answered are timing to surgery and what happened to the patients who elected not to undergo surgery in spite of weakness. It seems like these patients have a worse outcome. There is no defined time that is identifed to perform surgey (surgery within one week vs eight weeks) but I have seen a difference with delayed surgery for weakness. The data still needs to be processed.

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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