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  • AvatarLA_Frankie
    Participant
    Post count: 19

    I had microdiscectomy and decompression of L5/S1 4 weeks ago. The plan was to fix both L4/L5 and L5/S1 during the procedure but the surgeon felt there were not significant symptoms coming from the L4/L5. I was told that I presented with mostly S1 symptoms — back of leg, back of calf pain with accompanying weakness.

    However, when I re-read MRI reports (there were two) the L4/L5 sound more significant to me. The use of the word, ‘severe’ is most alarming.

    1st MRI

    1. The L4-L5 disc level demonstrates a shallow right posterior and proximal foraminal disc herniation is present causing focally severe right subarticular recess encroachment (sequence 5001, image 37), with presumed impingement upon the traversing right
    L5 nerve root. Evaluate for possible right L5 radiculopathy.

    2nd MRI

    At L4-L5, there is mild disc degeneration and disc height loss and associated annular fissure. There is disc bulge with prominent right subarticular component. There is resultant at least moderate narrowing of right subarticular zone and crowding of the
    descending nerve roots. There are moderate bilateral facet hypertrophic changes. There is no central canal stenosis. Neural foramina are adequately patent bilaterally. These are unchanged since prior exam.

    Impression from 2nd exam:
    At L4-L5 there is at least moderate narrowing of right subarticular zone with crowding of the descending nerve roots, stable since prior exam.

    As a surgeon, what would make you deviate from the original plan? I asked if the L4/L5 looked as if it were healing and was told, “We didn’t get a look at that level because we would have had to make a larger incision and cut more bone.”

    I was also told the MRI is only a static picture and what is goings on at the L4/L5 might not be causing any symptoms, and may heal on its own. Sounds like a lot of maybes and ifs.

    Do you think my situation warrants a second opinion?

    Thank you.

    AvatarDonald Corenman, MD, DC
    Moderator
    Post count: 7802

    I would hope that the first surgical plan did not include also operating on L4-5 only because it would be highly unusual to plan to operate at that level and cancel the plan intraoperatively.

    Some of the questions I have would be what was done with the diagnostics? Did your exam note only the S1 nerve involved with your symptoms and not the L5 nerve (sometimes hard to differentiate without motor weakness). Did you undergo any diagnostic selective nerve root blocks to “root out” the nerve or nerves involved?

    Your MRI reading notes L4-5 nerve compression according to the radiologist; “The L4-L5 disc level demonstrates a shallow right posterior and proximal foraminal disc herniation is present causing focally severe right subarticular recess encroachment … with presumed impingement upon the traversing right L5 nerve root”. I am unclear why the L4-5 level would not also be addressed surgically unless there was clear evidence that the L5 nerve root was not involved.

    Sometimes, “the proof is in the pudding”. How much better do you feel after only having the L5-S1 level addressed surgically?

    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.
    AvatarLA_Frankie
    Participant
    Post count: 19

    Thank you for the response.

    Due to the timing of my injury and the pandemic, the first time I actually met the surgeon ‘in person’ was the day of surgery. We had several video calls month to month where he was made aware of the symptoms. Some of the symptoms got better at first (motor loss in calf improved after 1st month) but then I aggravated/worsened the protrusion at L5/S1 which was confirmed by a 2nd MRI.

    The original surgical plan, made over the video calls, was to fix both levels although the surgeon reiterated that he believed most of my pain was due to the S1.

    I was set to receive an EMG test prior to surgery but when I ended in the ER and could not stand after worsening the L5/S1 level I opted for surgery.

    Day of surgery when he examined me, he never told me he would not do the L4/L5. However he did explain again that my pain falls along the S1.

    As you said, proof may be in the pudding. I feel a lot better. 80% of the symptoms are gone. I am just having the very dull, burning feeling in back of the upper leg. And the calf soreness/weakness has returned — although it has slightly improved in recovery.

    I see the surgeon for the first time since surgery next week and I will ask why he changed the plan, but also how does leaving the L4/L5 as is affect my rehab going forward?

    Dr. Corenman, lastly, what type of symptoms would a L5 impingement cause? I don’t know if what I am feeling post-surgery is from the L5 or the irritation of the decompressed S1…

    Regards,

    Frank

    AvatarDonald Corenman, MD, DC
    Moderator
    Post count: 7802

    To determine what nerves cause what symptoms, see this: https://www.neckandback.com/conditions/symptoms-of-lumbar-nerve-injuries/

    What side of the spine was the L5-S1 surgery performed?

    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.
    AvatarLA_Frankie
    Participant
    Post count: 19

    The surgery was done on the right side of the spine. All of my pre-op symptoms were down the right leg. Main location of pain was Rt glute/hamstring where the atrophy is now located. And as far down as my calf where the motor loss is still present but improving slightly.

    Frankie

    AvatarLA_Frankie
    Participant
    Post count: 19

    After reviewing the ‘Symptoms of Lumbar Nerve Injuries’ it doesn’t appear as though I currently have any of the L5 symptoms coming from the L4/L5 herniation.

    However when I read the S1 section, it is basically describing everything I had prior to surgery and some of the lingering symptoms — especially the ‘push off’ weakness when walking.

    Also the atrophy has occurred in the lower part of the gluteus maximus which sounds S1 related as well.

    I still am really curious why the surgery plan changed day of… maybe it’s a moot point if I am free of L5 symptoms.

    Thanks again for providing the link.

    Frankie

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