[PFCRANGER]

#7475

It has now been 15 days since my MITILF using a PEEK cage and 45MM rod, I still experience pain in my leg at times but not as bad as pre op. Its still very hard getting up from a laid down position and sitting position but seems to be getting a little better. Saw the doctor and the wound is ok, the strength has come back in my leg I would say about 60%. I will not be doing any type of rehab for at least 3 to 6 months. So we will see how the healing process continues talk to you soon.

[Donald Corenman, MD, DC]

#7478

Thanks again for writing back to us. The nerve seems to be recovering well. Every doctor has a different protocol for rehab. I am sure he has you walking and now your transitions from lying to standing are improving. Please continue to keep us posted- maybe in four more weeks at the six week follow-up.

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.

[catmadni]

#7499

Doc,

My situation is so similar to Pf’s that I responded to this post. Please advise if youn want me tore-post or move me as you see fit

I am a 48 year old male. I have had a anterior cervical microdiscectomy in 2001. Otherwise healthy.

I have suffered intermittent lumbar back pain, spasm, etc, without radiciopathy, for approx 12 years. This summer the episode were more frequent and unresolving.

On 9/28 I had a lumbar sacral MRI done which indicated several bulges and herniations to varying degrees. Most notably was a large herniations at L4/5 to the left. Again no radiciopathy of any kind, weakness, numbness, on the left side. I was scheduled for a epidural steroid injection. On 10/9 I had sudden onset of severe stabbing pain in the back of my left thigh. I was like an unrelenting “Charlie horse”. I lasted 3 days. Then my left rear butt, thigh, calf heel and particularly the side of my left foot were numb. It lasted 3 days. In the fifth day of this 6 day episode, I saw my neurologist who I told about the episode and during examination, he found no left ankle jerk. He remarked about the symptoms I was exhibiting seemed related to the s1 nerve root. However he told me to see a surgeon now.

I selected a neurosurgeon (NS) in some haste due to the neurological findings by the neurologist. The neurosurgeon examined me of course, and I mentioned the remarks of the neurologist regarding the S1 symptoms. He dismissed it that the symptoms could easily be related to L4/5.1. A posterior lumbar partial discectomy of L4/5 was scheduled for 10/21. However on 10/19 I realized that I had lost my ability to lift my self by my left calf

The planned surgery was done emergency on the basis that my new symptoms were a progression of the disease at the same L4/5 level.

Expecting to find complete relief immediately following surgery, as was the case with the 2001 anterior cervical microdiscectomy , I was disappointed. In fact I felt my symptoms were worse. I was convinced that something was missed.

I reiterated the onset of the “charlie horse” and the numbness symptoms with the NS. I even added a prelude event that had occurred. I thought little of this at the time because of its subtlety. A day prior to the onset of the “Charlie horse”‘ Iwhile doing some kitchen chores I felt a strange movement in my back.

I had deliberately laid the groundwork for the NS to do a follow up MRI, because he had reason to believe something occurred post the 9/28 MRI, in which it seemed he was entirely relying on. He ordered the MRI. Due to storm Sandy here on the east coast it was not until 11/6 that the MRI was read to indicate a large fragment from L4/5 had migrated down the canal and settled on the S1 nerve root.

A second surgery was done on 11/9. My loss of of calf raise is still the same. I am attending physical therapy for the leg only.

Sorry for so much detail. Not withstanding any misstep by anyone in this process, including myself, would it be safe to say that the nerve compression was always at the S1 nerve root which began at least at the onset of the “Charlie horse” pain on 10/9 and ended with the second procedure on 11/9′ or 30 days of compression? And considering the severe downturn in symptoms upon first compression, the duration of the compression, and my continued symptoms of calf weakness, what would you expect my eventual outcome to be? And what could I do to allow myself the best outcome?

I appreciate you reading my post and answering the questions at the end. I am concerned about being permanently impaired at such a young healthy age.

[Donald Corenman, MD, DC]

#7502

You had an MRI on 9/28 that demonstrated a large left herniation at L4-5 left. Less than two weeks later, you had significant increasing left thigh pain. The evaluation from the neurologist noted an S1 nerve involvement and you were referred to a neurosurgeon. Two days prior to the surgery, you lost the strength of the left calf muscle.

Your complaints are related to the left S1 nerve. It is unusual for a disc hernation at L4-5 to cause an S1 radiculopathy as a hernation here would typically compress the L4 or L5 nerves. Your presentation would make me uncomfortable with the diagnosis and I would want another MRI. You did however have an urgent situation with motor weakness.

This does present a problem because the insurance company just paid for an MRI one month previously and your symptoms were still in the same leg. There are many of these companies that would put up a fight to pay for another one. I would have to be on the phone for long periods of time to get approval and would be shuffled from one agent to another and finally to a “physician specialist” to hopefully gain approval.

The nerve was eventually decompressed and you are now in the recovery phase. It will take six months to fully know how much strength will return. I have my patients use a recumbent bicycle for early rehabilitation. Do not let physical therapy use an electrical stimulator for rehabilitation.

Please let the forum know about the process of your recovery in the next six months.

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.

[catmadni]

#7515

Doc,

Thanks for your quick response.

Everything in your recap is correct. However I was possibly unclear in my first post.

The second MRI on 11/6, post-op the L4/5 discectomy of 10/19, showed a large fragment (2cm in one dimension) of L4/5 disc material, had broken off, traveled down the canal, and settled on my S1 nerve root below. This event, the migrated fragment, is what caused my S1 radiculopathy.

Urgently, three days later, the second discectomy (L5/S1) on 11/9 included removing the migrated fragment the first surgery. Apparently he performed all this through the same, all be it newly enlarged, original laminectomy of 10/19.

You are exactly right that the S1 symptoms that were picked up by the neurologist were dismissed initially by the NS in favor of the 9/28 MRI. He obviously assumed my symptom were a progression of the same level.

I am obviously upset about the above mis-step and trying not to look back. Are you suggesting a third MRI? Essentially to confirm the he has now cleared both nerve roots? or should I be comfortable that the S1 nerve is decompressed and I am in the recovery phase?

If I am done with surgical procedures, and in recovery/rehab, I am concerned about yur comment on electric stimulator This is precisely what my PT specialist has done to me. My NS wrote for PT as “light PT for Left Leg only, Don’t Touch his Back, 2 days Per Week for 4 Weeks”

I know you already answered this question, sorry to push: Can you guess as to the extent of my motor recovery to the left calf? Could I say that it is ‘not totally unlikely that I make a full strength recovery?’

Followup questions: Are you suggesting a third MRI? Why not the electric stimulator? Is the recumbent bicycle indicated for calf weakness?

Thank you again. You are very kind to offer this forum

[Donald Corenman, MD, DC]

#7521

I think most likely that your canal has been decompressed and you are on the road to recovery. You now must wait for nature to take it’s course and allow the nerve to heal. I am just writing up a new section for the website regarding nerve healing and I will attach some of it here.

“The nerve was injured by the large disc herniation and even though the herniation was surgically removed, the nerve has yet to recover. The burning sensation is typical for a nerve injury. The reason the leg becomes weaker with activity is that only a small portion of the muscle cells are firing in that muscle group. Most of the muscle cells are not getting the signal from the brain to contract and the ones that are still connected are too few to give a normal contraction.

These working muscle cells fatigue easily as they are overloaded with work and cannot “keep up” with the load. This is why with continued exercise, the leg feels weaker.

Muscle cells that are not connected to the brain are called “deinnervated”. These cells have a number of ways to recover but this takes time. Some of the recovery methods are functional recovery, nerve budding or sprouting, myelin sheath repair, nerve regeneration and muscle hypertrophy.

The first recovery method is functional recovery. You have experienced this yourself in the past. When you rest your elbow on a hard counter and your “hand goes to sleep”, you have actually temporarily blocked the ulnar nerve by this compression. This causes a temporary physiological block. When the pressure is removed, the nerve recovers relatively quickly.

Budding is a phenomenon where the deinnervated muscle cells puts out a neurochemotactic factor. This is a chemical “cry for help” and any close functioning nerve will bud or sprout a branch to connect with this muscle cell. This can take 12-16 weeks.

Myelin sheath injury. This is the condition where the insulation of the nerve itself that was damaged. These myelin cells will regenerate which allows the signal to continue down the nerve. Myelin sheath repair takes anywhere from 2 weeks to 16 weeks.

The third recovery method is by axonal regeneration. If the nerve was severed but the insulation sheath (myelin) was left intact, the nerve can grow down this pathway. The nerve grows at about one inch per month. The problem with the S1 nerve is that it is the longest nerve in the body with some examples at 22 inches long. It could take many months for the nerve to grow down to the muscle in the leg (this is assuming the insulation sheath is still intact). If it takes longer than 12-18 months to reconnect with the muscle cells, these muscle cells will atrophy and fibrose. This means that even if the nerve grows and reconnects, the muscle cells will be useless and not be able to contract.

The last possibility for recovery is muscle hypertrophy. Arnold Schwarzenegger is what many individuals think of for muscle hypertrophy and that thought is not far off. The residual muscles can be conditioned to become stronger and last longer. Training is the key for this and this result may take three of more months of hard work to achieve success.”

The reason that I don’t recommend electrical stimulation is that there is some literature that notes the budding or sprouting phase of nerve repair is stunted by stimulation. It appears that the neurochemotatic factor might not be released by the muscle cells if electrical stimulation is used.

I think you have a good chance of useful muscle strength recovery with your surgery. It might take some time, but don’t be frustrated.

Please keep the forum informed regarding the course of your recovery.

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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