[Donald Corenman, MD, DC]

#35287

You are now 2.5 years out from a microdiscectomy of L5-S1 right with a “new” recurrent disc herniation “right disc herniation pressing on the sac, pushing the root of S1 in the canal space on the right as well as on the root of L5 out the right foramen”. This disc herniation is also compressing the right L5 root in the foramen. You still note symptoms of S1 (and maybe L5) nerve compression or dysfunction.

You also note discogenic pain “I still have problem with sitting on straight chair mechanical pressure sets in shortly after followed by discogenic pain after 1-2 hours” but you do not differentiate this pain from possible radiculopathic pain (nerve pain that appears to be unilateral lower back pain). Is your back pain central (both sided) or only unilateral?

You then have questions.
1. “will I’ll be able to sit more time freely without any mechanical pressure causing discogenic pain? i.e does “no motion no pain” principle applies mainly to vertical disc motion (instead of shock absorption in a normal healthy disc)?”. If you are having discogenic lower back pain and that pain is limited to the L5-S1 level, a fusion (TLIF, ALIF or OLIF) should reduce substantially your lower back and leg pain (as long as a decompression is performed with your fusion). However, if your unilateral lower back pain is nerve and not disc generated, a simple decompression without fusion can be considered.

2) “From a nerve recovery perspective is there any medical logic of fully decompressing the nerves 3.5 years after the initial damage or to much time has passed and will have no effect on the L5 nerve root damage?” Yes. I have found that there can be improvement even years later decompressing a nerve root.

3) “Other then stiffness what “new” pain fusion may bring after successfull recovery (6-12 months)”? In general, fusion makes the back better but not perfect. If the surgery is not performed correctly or the fusion does not fully fuse, continued pain can occur.

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]

#35318

“Is your back pain central (both sided) or only unilateral?”
I didn’t know that back pain could be unilateral. it’s not from the left (healthy) side. it’s central and right accompanied by inflammation (burning sensation) exactly where the discectomy and laminectomy were done.

“If you are having discogenic lower back pain and that pain is limited to the L5-S1 level, a fusion (TLIF, ALIF or OLIF) should reduce substantially your lower back and leg pain (as long as a decompression is performed with your fusion)”

1. Isn’t nerve decompression comes “built-in” with fusion? when you restore proper disc height the foramen should be wide open and the is no herniated disc to pinch the nerve.
2. Are different fusion techniques suitable for different pathologies? e.g (from what I saw and understood) ALIF could be a better option for single level fusion with no spine instability or deformities it’s less destructive and could be done without the support rods connected to spine by pedicle screws.

Just uploaded my latest MRI scans (https://drive.google.com/file/d/1rMgnLd3zDCY81HraAJZEmCox9FdPvleB/view) and sent them to the neurosurgery unit where i’m treated. from the saggital view you can clearly see the re-herniation on L5-S1. L4-5 is degenerative as well with an annular diffuse bulge but still intact and doesn’t cause any back pain or pinch nerves.

Thank You

[Donald Corenman, MD, DC]

#35319

“I didn’t know that back pain could be unilateral. it’s not from the left (healthy) side. it’s central and right accompanied by inflammation (burning sensation) exactly where the discectomy and laminectomy were done”. Nerve pain can mimic unilateral lower back pain. Sometimes it is difficult to differentiate.

“Isn’t nerve decompression comes “built-in” with fusion? when you restore proper disc height the foramen should be wide open and the is no herniated disc to pinch the nerve”. Not always. If there is a collapse of the disc allowing the nerve to be compressed, then the restoration of disc height through a fusion will decompress the root. If however, there is a mass in the spinal canal (herniation), the realignment by fusion will not decompress the root. You would need a direct decompression of that nerve root (microdiscectomy).

“Are different fusion techniques suitable for different pathologies? e.g (from what I saw and understood) ALIF could be a better option for single level fusion with no spine instability or deformities it’s less destructive and could be done without the support rods connected to spine by pedicle screws”. The answer is unsupported anterior fusions (ALIF/OLIF) without the posterior instrumentation (pedicle screws) has a much higher failure rate due to the lack of ability of anterior instrumentation to “grab hold” or “bite” into strong vertebral structures. This “lack of hold” allows motion which can lead to nonunion or “no fusion”.

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]

#35353

Dr. Corenman

I’ve seen the surgeon a month ago he said that in his opinion the compression I have does not require further surgical intervention (discectomy or fusion) . He is conservative and probably doubtful if a fusion will get my spine better then it is now. I’m gonna get a 2nd opinion.

1) The foot seems slowly getting better but I’m still suffering from my back in essence I feel already somewhat fused if I do 50-60% BLT postures I’ll get discogenic pain (and probably inflammation) reaction(s) what is the point of not getting that level fused if it is stiff and prone to pain?

2) There is a cycle I don’t understand: in the morning the foot paresthesia is at it’s worst – painful to walk and put some non cushioned shoes or sandals it gets better (more sensation) as the day progress and at night while lying in bed completely horizontal it feels like the nerve is growing/recovering sense of pleasent heat and tingling it can last couple of hours or so the foot is much less sensitive to pressure (and consequently less painful) but in the morning the story returns all over again. what are your thoughts about it? do you think inflammation has to do with it though it looks like it’s the same cycle even when my L5 -S1 disc is very guarded (unless a very degenerative disc is almost always inflammed not matter if it moves or not)

3) Lastley do you know any of these supplements : L-Citrulline, Acetyl-L-Carnitine, R-Alpha Lipoic Acid , Benfotiamine helpful for non-diabetic neuropathy and or nerve regeneration?

Thank You Dr. Corenman

[Donald Corenman, MD, DC]

#35356

“Dr. Corenman

I’ve seen the surgeon a month ago he said that in his opinion the compression I have does not require further surgical intervention (discectomy or fusion) . He is conservative and probably doubtful if a fusion will get my spine better then it is now. I’m gonna get a 2nd opinion.

1) The foot seems slowly getting better but I’m still suffering from my back in essence I feel already somewhat fused if I do 50-60% BLT postures I’ll get discogenic pain (and probably inflammation) reaction(s) what is the point of not getting that level fused if it is stiff and prone to pain?

2) There is a cycle I don’t understand: in the morning the foot paresthesia is at it’s worst – painful to walk and put some non cushioned shoes or sandals it gets better (more sensation) as the day progress and at night while lying in bed completely horizontal it feels like the nerve is growing/recovering sense of pleasent heat and tingling it can last couple of hours or so the foot is much less sensitive to pressure (and consequently less painful) but in the morning the story returns all over again. what are your thoughts about it? do you think inflammation has to do with it though it looks like it’s the same cycle even when my L5 -S1 disc is very guarded (unless a very degenerative disc is almost always inflammed not matter if it moves or not)

3) Lastley do you know any of these supplements : L-Citrulline, Acetyl-L-Carnitine, R-Alpha Lipoic Acid , Benfotiamine helpful for non-diabetic neuropathy and or nerve regeneration?”

Fusion can be helpful for discogenic or facetogenic pain that does not respond to therapy if the level or levels can be absolutely identified and proved to be the pain generators. A significant course of physical therapy needs to be undertaken before surgical back pain treatment is considered.

You note “in the morning the foot paresthesia is at it’s worst” which is typical as the root will swell when you are lying down due to your supine positioning. When you stand, gravity takes over and the swelling is reduced.

The supplements you note are not proven to be helpful as there are no studies but should not be harmful for most individuals. Membrane stabilizers (neurontin, Lyrica) might be helpful as they work to make you drowsy and can last up to 8-12 hours.

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]

#36295

Dr. Corenman

I’m 5.5 years after the LDH

I’m still suffering from numbness, pain & paresthesia when there is a pressure on the balls of right foot it could be while walking, standing or sitting. the pain gets relieved while lying down.

Last MRI from 4 moths has shown
L5-S1: “Peripheral disc bulge with forminal and extra forminal right degenerative disc. Light impression on the right lateral recess. Severe foraminal stenosis from the right with pressure on L5 from the right”

2nd opinion surgeon I’ve gone to said that only TLIF can free the stenosis and the nerve root but he doesn’t know if the nerve is not permanently impaired.
He’s suggestion is to do a transforaminal SNRB and if there is any improvement in pain levels there is a place to do the TLIF.

What is your opinion on that?
Does the TLIF “worth” the chance of getting improvement on the nerve conduction after so long?
PS I’m also suffering from back pain once in while but it’s manageable.

Thank You Dr. Corenman

[Author]

Posts