L 4 radiculopathy

Tagged: Herniated disc in lower back leading to leg weakness

Viewing 5 posts - 1 through 5 (of 5 total)

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SHuck
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September 10, 2017 at 3:55 am

Post count: 3

#26290

Dear Dr Corenman,
I am a British retired GP. 8 weeks ago I developed an L 4/5 disc lesion with a small sequestrated nodule impinging my left L 4 nerve root on MRI scan.I had horrible L anterior thigh and shin pain for several weeks- now settling to occasional twinges. I have had no paraesthesia or numbness. I have had fasciculations in my L quadriceps which are ongoing but less than 6 weeks ago. Last week I noticed L quadriceps wasting and on now starting to mobilise realise that I have L quadriceps weakness and mild foot slap on walking more than a few 100 yards. In addition after walking a mile or so my L leg feels a bit unstable and weak. I am a very keen mountain walker and road and mountain biker and I am now very worried.
I suspect I need a microdiscectomy to relieve the nerve root. If my pain is so much better is it likely that I will still have nerve root pressure that might cause further nerve loss and subsequent muscle weakness? Would a conservative approach be a reasonable option at this stage? What do you feel my chances are of a good recovery here that might allow me to cycle and walk strongly again? I realise from reading your information pages that any tibialis anterior problem is likely to be permanent.
Many thanks.

Donald Corenman, MD, DC
Moderator

September 10, 2017 at 6:59 am

Post count: 8660

#26291

An L4-5 disc herniation that compresses the left L4 nerve root is a far lateral herniation. 95% are in the canal as a posterolateral hernation compressing the L5 root and only 5% are in the far-lateral position compressing the L4 root. The L4 root is more sensitive to compression than the L5 root and typically innervates the quadriceps muscle (but can innervate the tibialis anterior too). Your complaint of quad weakness with foot drop fits this nerve perfectly.

Faciculations of the quad muscle typically occur as the first signs of denervation. The progression is fasciculation, wasting and weakness. There are times that pain is not present with compression and times that the nerve is so compressed that the nociceptors are dysfunctional and the condition is painless. There is a condition called Parsonage-Turner syndrome (that normally occurs in the shoulder but I have seen occur in the leg rarely) that could explain your weakness but if you have a documented far-lateral herniation, most likely this is the cause of weakness.

It is my practice to decompress the nerve in the face of motor weakness within a week (or sooner)> I am completing a study on timing of weakness and decompression and it seems that the sooner surgical decompression occurs, the better the outcome. See https://neckandback.com/conditions/how-muscles-recover-from-nerve-injuries/ and https://neckandback.com/conditions/parsonage-turner-syndrome-neck/.

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.

SHuck
Participant

September 10, 2017 at 7:20 am

Post count: 3

#26293

Dear Dr Corenman,
Thankyou for your advice for which I am very grateful. Might I ask whether with your experience you feel it possible in my case that nerve decompression at this stage could lead to a recovery that might allow me to walk and ride strongly again. Also is it possible that my quadriceps weakness will only ever be partial because L3 might also be innervating my quads allowing some substantial function to remain. I can still climb and descend stairs etc.
Apologies for multiple questions.
With many thanks.

Donald Corenman, MD, DC
Moderator

September 10, 2017 at 7:44 am

Post count: 8660

#26298

It has been my experience the recovery can still be possible. There are patients who do recover without surgery but I think that surgery doubles the chances of root recovery. Yes, L3 also innervates the quad so you would not have complete failure. You can test the quad by doing one-legged squats on the affected side. Crouch as far as you can and try to raise up repeatedly without help (but keep a hand on a counter surface as to prevent leg collapse). If you can raise up without help multiple times, your quad is not too bad.

The descent of stairs requires eccentric contraction of the weakened quad and is the toughest maneuver of this muscle. If that descent onto the weak leg doesn’t require you to hold the hand rail, that is also a good sign.

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.

SHuck
Participant

September 10, 2017 at 8:02 am

Post count: 3

#26299

Dear Dr Corenman,
At the risk of becoming a nuisance can I ask whether at 8 weeks any nerve injury is likely to be complete or could further damage continue if a conservative approach is taken?
Also do you know why I have had no altered sensation or numbness. I foolishly took this as a reassuring sign and was shocked to find my quad wasted.

PS your information pages on spinal problems are the most informative I have ever read and I wish I had known of them as a practising GP.

With many thanks again.
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Donald Corenman, MD, DC

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Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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