[onedante]

#20540

I have a 69 y/o pt. with a re-heriation at L$_% and caudal migration of a disc fragment compressing the L4 nerve root. An epidural done 19 days ago gave him 70% relief of severe hip, groin.thigh pain, but he started to develop weakness and atrophy in the quad about the time of injection (L5-S1)

He was to a local neurosurgeon and was recommended for L4-5 TLIF due to co=existing (but asymptomatic) foraminal stenosis. He agreed to the surgery, but now is having second thoughts.

His question to me is this: At my age I think I only have 2-3 years left of active lifestyle. Is it worth giving up a year for post op healing or should I just suck it up w/ medication and live it up. The most important thing in his life is motorcycle riding (standard sport bike w/ upright seating position. He rode a 300 mile loop last week in one day w/o increase pain. He does some light hiking.

If he does not do the surgery, what can I tell him is his worst case scenario would be.

Thanks for your thoughts,
Dante Langston PA-C

[Donald Corenman, MD, DC]

#20543

I assume L$_% is L4-5 (I make this mistake with some frequency too).

A re-herniation at L4-5 that compresses the L4 nerve root would mean that this extruded fragment migrated upwards into the foramen as the L4 nerve exists above the disc through the foramen. The L5 nerve traverses across the disc and is more commonly compressed by an L4-5 disc herniation. I will assume that the fragment is compressing the L4 nerve root as the L5 nerve root would not cause hip/groin pain and would not cause motor weakness of the quad muscle.

A recurrent disc herniation (second time) generally does not require a fusion but simply a repeat microdiscectomy. I think that there is a time constraint here. In my opinion, this nerve needs to be decompressed sooner than later. The quad muscle can recover without a decompressive surgery but the recovery chances are significantly improved with surgery and sooner than later.

Sport bike riding requires a good quad muscle especially when stopping where that leg is extended to hold the rider up when the bike leans to the side. He could always try to lean to the other side but in my riding experience, that does not always consistently happen.

Worst case scenario is that the quad muscle does not recover and he will always have to be careful with support from that leg especially climbing and descending stairs. He might also have chronic pain in that leg.

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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