[rypz79]

#32185

Hello Dr. Coreman,

My name is Roey and I’m 40 Y/O male from Israel.
FOA I have to say this is a great website very informative and well designed.

My case:
Neurological diagnose: Thoraco-Lumbar – Disc herniation w/ radiculopathy.
Main complains: Numbness and burning pain in R foot.

Aprox. 9.5 months ago experienced acute onset of LBP associated with RLE postlateral radiating pain a and R foot plantar surface numbness after lifting heavy object.
Received epidural steroid injection on 01/19/20 with minimal relief.
SXs has largely improved except for persistent R foot plantar surface numbness and burning pain, unable to tolerate wearing of closed footwear and prolong sitting or cross-legged.
No changes in bowl and bladder function.
Elective admission for minimally invasive discectomy on 2/24/20.
Alert and oriented, bilateral D/BT/HG/IO 5/5 , bilateral HF/KE/DF/EHF/PF R foot plantar surface
diminished sensation to touch.
No hoffman, Babinski, clonus or hyper-refelxia.
MRI – L spine 12/17/19 R L5/S1 paracentral and far lateral disc herniation with neural foraminal stenosis.

5 days after the surgery I’m feeling a little improvement in the sensation and less pain while stepping on my right foot

My questions are:
1) Did I had the nerve decompression surgery on time (what is the “optimal” time ?) so my L5 nerve root will heal completely and I won’t have any neurological loss ?
2) Can I conclude from my symptoms how severe was the damage to the nerve ? i.e does symptoms severity combined with compression time can roughly estimate the damage level, recovery time and healing % ?
3) How long it would take for it to heal and what are the signs for that ?
4) Can I do anything to hasten the regeneration process ?

Thank you very much Dr.
Best Regards
Roey

[Donald Corenman, MD, DC]

#32187

You had a complex disc herniation with 2 nerve roots compressed “MRI-L spine 12/17/19 R L5/S1 paracentral and far lateral disc herniation with neural foraminal stenosis”. A paracentral herniation will affect the S1 nerve root and a far-lateral herniation affects the L5 root. It is the far-lateral herniation component that I worry about as this particular portion of the fragment is very difficult to retrieve from the typical approach that is used at L5-S1.

There is no current paper that indicates proper timing of removal but generally, faster is better. It also worries me that you have the symptom of “unable to tolerate wearing of closed footwear” as this indicates an allodynia which can be related to chronic root injury. This symptom however can improve over time even with chronic root injury.

You ask can “symptoms severity combined with compression time can roughly estimate the damage level, recovery time and healing?. Probable with exceptions.

You ask “How long it would take for it to heal and what are the signs for that? up to one year with diminishing pain, paresthesias, irritability and numbness.

You then ask “Can I do anything to hasten the regeneration process?”. This is the art as well as the science of medicine. Don’t overly stretch the root to trigger increased symptoms but don’t ignore stretching where the root can be elongated without flairup.

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.

[rypz79]

#32209

The “unable to tolerate wearing of closed footwear” is an exaggeration.
I copied it all right of the hospital release letter.
I was/I am able to wear closed footwear the thing is like with prolonged sitting or cross legged sitting or stretching the leg while laying on my back it puts more pressure thus more pain on the traversing sciatic nerve which goes all the way back to the L5 nerve root.

A paracentral herniation will affect the S1 nerve root and a far-lateral herniation affects the L5 root. It is the far-lateral herniation component that I worry about as this particular portion of the fragment is very difficult to retrieve from the typical approach that is used at L5-S1.

What do you mean by “typical approach”?
The surgeon said that he removed the disc fragment and after that moved the L5 nerve root in all directions to make sure it’s free.
I can ask him what approach he took all I know it was under a microscope rather then an endoscope.

Is there a scenario in which both L5 and S1 nerve roots should’ve been decompressed? the 3 neurosurgeons I consulted only talked about L5 nerve root pressure.

Thank you very much Dr. Coreman
Roey

[Donald Corenman, MD, DC]

#32210

If a fragment is in the far-lateral position, the fragment is outside the canal, lateral to the side of the disc. The removal is normally approached through the far-lateral technique. This technique however cannot be used at the L5-S1 level due to the particular anatomy of this segment.

The typical approach for any disc fragment in the canal is a posterolateral approach which doesn’t allow access to the far-lateral position. The fragment therefore needs to be “fished out” indirectly or needs to be removed by taking off the facet which destabilizes the segment, requiring a fusion of L5-S1.

Your MRI noted: “R L5/S1 paracentral and far lateral disc herniation with neural foraminal stenosis”. Since we now know that the facet was not completely removed (or you would have had a fusion), there is a chance that the fragment was not completely removed. If you don’t get significantly better, a new MRI with gadolinium might be in order.

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.

[rypz79]

#32321

Hello Dr. Corenman,

I have 4 more questions please:

1) If the lumbar nerve roots are myelinated and it takes 8-14 weeks for the myelin sheath to recover can’t we conduct something about the recovery process after 14 weeks?

2) If the nerve grows about an inch a month or a feet a year what does it mean about recovery of along the L5 dermatome map? i.e the far it’s from the nerve root (like the foot or sole) the poorer are the chances of sensory recovery?

3) Is the nerve damage clock starts with the onset of the herniation or the symptoms of the radiculopathy? Does the healing time talked in this article starts in affect from the time of the decompression surgery?

4) Why walking outside (not barefooted) or sitting leg on leg for a period of time (that can be increasing by the day) aggravates my symptoms?

Thank You
Best Regards
Roey

[Donald Corenman, MD, DC]

#32329

1) If the lumbar nerve roots are myelinated and it takes 8-14 weeks for the myelin sheath to recover can’t we conduct something about the recovery process after 14 weeks?

After 14 weeks without recovery, this could still turn out to be a myelin injury as all this time does without recovery is to rule out functional injury or myelin injury.

2) If the nerve grows about an inch a month or a feet a year what does it mean about recovery of along the L5 dermatome map? i.e the far it’s from the nerve root (like the foot or sole) the poorer are the chances of sensory recovery?

When you mention dermatome, you are talking about pain and sensation (numbness). This is different that a “myotome” which indicates muscle strength. The speed growing down the myelin tube is generally reserved for motor deficits. For an L5 root that affects the Tibialis anterior, EHL and gluteus medius muscles, if the nerve cell itself is disrupted from a traction of compression injury but the insulation (myelin sheath) is still left intact, the nerve can regenerate.

Since the nerve length to the point right below the knee (where the nerve enters these muscles) is about 18 inches and this is where the nerve enters the tibialis anterior and EHL muscles, this length is generally too far for the nerve to recover in this situation. However, the gluteus medius muscle motor point (where the nerve enters the muscle) is only about 6 inches from the injury point so this muscle has a much better chance of recovery.

3) Is the nerve damage clock starts with the onset of the herniation or the symptoms of the radiculopathy? Does the healing time talked in this article starts in affect from the time of the decompression surgery?

The clock starts with the nerve injury or when the herniations occurs.

4) Why walking outside (not barefooted) or sitting leg on leg for a period of time (that can be increasing by the day) aggravates my symptoms?

If the nerve root is inflamed, pushing and pulling it (walking and flexing the hip) will aggravate it.

See https://neckandback.com/conditions/how-muscles-recover-from-nerve-injuries/

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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