[rypz79]

#32898

Dr. Corenman,

I miss calculated the post-op time. on 25th it will be 6 months.

I’ve written about my numb skin just to describe to anyone who doesn’t have numbness how it feels like but I guess it wasn’t good analogy.
I think the best way I can describe it is walking on a blister or on a bubble it feels like dead skin.
When walking outside this “bubble” spreads along the the whole sole and to recover from the soreness it produces almost instantly you to need to rest preferably with your leg up.
I think I’m making mistake comparing my right foot to the healthy left one but on the other hand I cannot tell what is a “normal” foot feels like.

Hypersensitivity of the skin (hyperalgesia or allodynia) can occur. A simple brushing of bed sheets on exposed skin can cause intense pain.

No I don’t think I qualify for allodynia, thermal or mechanical. When I said alternates I meant “when it’s painful the pain feeling alternates”…it’s not always painful.
In saying numb/numbness I mean loss of sensation not lack of sensation. The threshold for hot/cold sensation is 70-80% of the other foot that’s fair I can live with that.

Putting all my body weight on my foot balls (standing on my toes in point position) for a period of time will aggravate the nerve there is no such problem in the other foot. It also applies for prolonged sitting leg-over-leg (only for right over left) and for walking distances. The accumulated pressure on the balls of the foot or on their nerve path is currently limited and symptomatic (causes soreness and some burning sensation along the whole sole)

I think I’m doing a little bit better on Idle state the numbness/bubble has shrunk to the area beneath my big toe ball. There are less flairups (i.e feeling of burning feet) after prolonged sitting or walking, but still it’s not asymptomatic (I’ve heard many peopole with lower somatosensoric nerve issues that their sole is just numb, they don’t feel anything) and draws my mind’s attention regularly. also sometimes I feel a little bit of tingling on the dorsum of the foot though it still feels numb the sensations hot/cold/touch feels normal.

I’ve been put on pregabalin (started 75mgx2 /day then after a week 150×2 /day) I really hope it’s temporary and not the real cause of my improvement so I won’t use this medication on a regular basis for the long run.

I’ve measured the distance from the L5 exit (I have a scar there) through the thigh⋚ till the end of the foot it’s roughly 4’1 (I’m 6’1) so if the nerve recovers at 1mm per day it will take it almost 3.5 years to get there seems highly unlikeabke. Like you’ve written and said those wallerian degeneration are generally preserved (may I add exclusively?) for effernt neurons recovery.

If so then what is the recovery methodology for afferent neurons in cases of axonal death and some myelin damage distal to place of injury? i.e how CAN they recover from such long distance with relatively short time ?

Thank you Dr. Corenman

[Donald Corenman, MD, DC]

#32899

So you are now 6 months out from the decompression with continuing symptoms of “root irritability”. Even though this is not true allodynia, your symptoms are along that line. Allodynia is an injury to the sensory root as compared to the motor root which recovery rules are generally written. The “one inch per month” rule is written for motor strength recovery and the normal motor point of nerve connection to the muscle is considered “near the knee” so recovery has less distance to travel.

Sensory recovery is less certain as the healing root length has to travel down the whole leg to the foot. It will take longer but there is no limiting muscle factor that can atrophy (fibrose) in 18 months.

See these to understand how nerves heal.
https://neckandback.com/conditions/peripheral-nerve-anatomy/ and
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.

[rypz79]

#32915

Dr. Corenman,

what is the recovery methodology for afferent neurons in cases of axonal death and some myelin damage distal to place of injury? i.e how CAN they recover from such long distance with relatively short time?

I did not questioned it right.
I meant how can I feel some improvement with only 6 months gone by?
Is there a “critical mass” of connected neurons from which the nerve becomes “non-irritable”?

By asking about CAN & Methodolgy I meant about a gradual improvement as opposed to connected/not conneted (on/off) situation I understood from your articles.
Improvement that is some shrinkage in the numb area and less irritation (it takes more time to provoke it).

I’ve read a bit and found out that the 1 mm/day or 1 inch/month is a thumb rule first detailed in “Rate of regeneration of peripheral nerves in man” HJ Seddon et al. J Physiol. 1943. (p191-215)” In “Nerve Regeneration: Tissue Engineering Strategies (2006)” Recknor JB and Mallapragada SK cited that “Human axon growth rates can reach 2 mm/day in small nerves and 5 mm/day in large nerves.” So I guess there are several factors involved here and the axon growth rate is not a constant number.
From your clinical experience what is more accurate in lumbar radiculopathy cases ?(nerve root->sciatic nerve->terminal branches)

Two more questions in your permission:
1) Can the wallerian degeneration process have already started in the distal segment several days/weeks after the LDH together with the denevration process from the proximal segment? 
2) Can TENS treatments promote PN regeneration or mitigate “nerve irritability” symptoms? modernneuropathy.com/5-best-e-stimulation-devices-for-nerve-regeneration/

The buttom line is that it’s more harder for mentally then physically those irritations & limitations increase my level of anxiety and depression and can cause me panic attacks.
I could’ve handle the burning, numbess & pain much better if I only knew that this is a residual phase for a relative short time frame (upto a year or so post-op) after which the nerve will become “stable” or asymptomatic without allodynia pathological lines.
I can live with numb patches and/or some loss of sensation thresholds.

Thank you very much Dr. Corenman

[Donald Corenman, MD, DC]

#32920

Nerves recover based upon the type of injury. The problem is the type of injury cannot be discerned by current symptoms, only by the length of time of recovery which does not help with prognosis (how you are going to do in the short and long term).

See https://neckandback.com/conditions/peripheral-nerve-anatomy/

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]

#33571

Dr. Corenman

This is a summary of the Radiologist on the MRI check I did on the 12/18/2020:

The test was performed on sagittal and axial planes in the STIR, T2, T1 series and DIXON reconstructions w/ & w/o gadolinium IV injection.

Reason for referral: Still pain while stepping and foot paresthesia 8 months after forminotomy and discectomy at height L5-S1 on the right. 

In comparison from MRI dated 12/17/2019:
Findings:

……

L4-L5: Slight lowering of the disc. Diffuse disc bulge causes slight pressure on the spinal canal, slight bilateral stenosis on neural foramen, slight pressure on the L4 neural root.

L5-S1: Right para-median and foraminal disc herniation.  Narrowing of the right neural foramen and pressure on the L5 neural root.

The findings appear to have no significant change from the previous test. There is a lowering of the disc.

After a gadolinium injection there is a Contrast Medium Enhancement (CME) of the:
[] Interspinous ligaments at level L4-L5
[] Facet joints at levels L4-L5, L5-S1
[] Surgical tract in the forminotomy area at  level L5-S1 on the right

Conclusions:
There is still narrowing of neural formina at level L5-S1 and pressure on the L5 neural root both on the right

I’m 11 months post-op there is much improvement in the sensation still there are symptoms of stabbing needls and electric shock and it is painful to walk distances especially if you are wearing tight/slim/unstable shoes , the sole is still numb on the foot balls but there is more sensation heat/cold threshold are up compared to the healthy one. My back is sore I feel like “sitting on eggs” every wrong movement can light it up classic discogenic pain. I need to change postures frequently and take NSAIDs as well a 300mg of Pregabalin daily. As the results say I feel that the nerve root is not fully free and it’s affecting both it’s healing and day to day condition.
I have 1 year post-op on appointment with the surgeon at beginning of March.

My questions are:

1) What we can conclude from these MRI findings? Are the MCEs a direct consequence of improper disc space or height which results in a chronic inflammation?

2) recently I’ve been studying about an artificial (sometimes called total) Disc Replacement procedure. The specific prosthesis is called M6-L by Spinalkinetics. Unfortunately it’s not done were I live (I’ll have to question the surgeon to make sure though) and it’s very expensive abroad ~40k$. 

What do you know about these DR procedures? Do you it’s the best solution for one level LDH to those who still want to have active lifestyle in contrast to disc fusion were the back’s mobility & flexibility is impaired and the pressure goes up to the previous level in my case L4-5 which also starting show signs of wear and tear.

Thank You
Roey

[Donald Corenman, MD, DC]

#33573

You appear to have a recurrent disc herniation at L5-S1: “Right para-median and foraminal disc herniation. Narrowing of the right neural foramen and pressure on the L5 neural root”.

Total disc replacements (TDR) or “arthroplasty-ADR” works well in the neck but are not very good in the lower back. Also, even if you selected a TDR for your lower back, you would still need not just an anterior approach (through the belly incision) but still would need a posterior redo decompression to free the nerve. This procedure might require removing significant facet bony mass which could make the facet incompetent. An intact and functioning facet is necessary to allow a TDR to function properly.

If you have a foraminal recurrent disc herniation, you might be better off with a TLIF (transforaminal lumbar interbody fusion), This will remove the facet to free up both nerve roots and prevent any further herniations at this level. The alternative is a redo decompression as long as the herniation is retrievable without taking too much more facet.

https://neckandback.com/treatments/transforaminal-lumbar-interbody-fusion-tlif/

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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