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  • Hoosemec
    Member
    Post count: 8

    Hello Doctor Corenman,

    Your website is an excellent source of information, and the time you take respond to concerns of people is quite remarkable.

    I am a generally fit 46 year old man 5’9” 185 lbs. Two weeks ago I had a revision micro/discectomy/foraminotomy performed on the L5S1 level. I had been suffering some relapses for the last 3 years, but 2.5 months ago, I ended up with severe 10 out of 10 pains from sciatica, with very little relief over that duration and a huge downgrade to quality of life. The MRI report stated “small amount of enhancing scar around the left S1 nerve, disc thinning and degenerative changes in disc, moderate left Para central disc herniation/protrusion impinging the left S1 nerve root”

    The original discectomy was performed in 2001 for left leg pain and some foot weakness. It was an open procedure. It was discovered during the revision surgery that the ligamentum flavum was laid back down and left in place after it had been dissected during the original procedure. This resulted in an excess of scarring around the thecal sac and nerve. The Surgeon firs had to decompress this left over ligament first then proceeded to remove the offending disc (about the size of the tip of a pinkie finger). The nerve was not as mobile due to scarring in, and therefore, the Surgeon had to push the herniation down in order to visualize and remove it due to the nerve’s limited mobility.

    My main questions are:
    1. I awoke with numbness on the left side of my left foot, my left calve, and back of left thigh. I did not have this prior to the surgery at any time. I have read this can occur more frequently in revision surgery, what are your thoughts?
    2. My sciatica was gone after the procedure for the first 2 days, then crept back about 20% just in the left butt and slightly down the left back of leg to mid thigh. It was much more intense and far reaching before the surgery. However, I can intensify the sciatica by just palpating my back in the area of the surgery (push and feel more sciatica). This has me very concerned. I had this issue prior to the surgery and it was much worse then. Is this lingering inflammation, is this normal?
    3. I was told I could return to work after about 1.5 weeks. It’s been two weeks. I am a Project Manager am required to drive 45-60 minutes each way to work, then sit in meetings that can last anywhere from 1 to 2 hours or longer. This seems aggressive and I don’t feel I could handle the discomfort at this time, nor would I want to compromise my recovery. What are your thoughts on returning to work with for my type of work?
    4. Where can I find the best advice and exercise to mitigate scarring during the healing process?

    Thank you.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    The numbness that you find present might have been present prior to surgery but “covered over” by pain in the same area. When the pain abates, the numbness is noted. Manipulation of the nerve during surgery can also create numbness that was not present prior to surgery. Normally, this numbness will disappear over time.

    Pain that was not present immediately after surgery can recur in some patients but not normally to the same intensity as prior to surgery. This can occur from the inflammatory cascade (it takes some time for inflammation and swelling to occur), from hematoma (a small amount of blood in the canal can cause inflammation or compression) or from a recurrent herniation (rare but known to happen in the immediate post-operative period).

    There is a very small change of the presence of chronic radiculopathy (a preexisting injury to the nerve from the herniation-see website) but that is unlikely.

    Return to work depends upon the patient and occupation. If you were one of my professional athletes, you might not go back to competition for 8 weeks. If you were an attorney or CEO, you might go back to work in one week (part time-light duty). Some patients walk out of the hospital without any symptoms and some are uncomfortable for two weeks. Sitting is always the most symptomatic of the prolonged positions in the immediate post-operative period.

    You normally want to start nerve glides in about 10 days after surgery. The root should be free of adhesions immediately after surgery and the normal response of the body is to form scar tissue. The nerve root should move about one centimeter with leg or back motion. This is why physical therapy is helpful for prevention of adhesions. The technique is called nerve flossing and is self-descriptive.

    Dr. Corenman

    Hoosemec
    Member
    Post count: 8

    Doctor, thank you for your previous responses.

    How long before I can get an MRI to clearly see if the disc reherniated?
    Should I request an injection now to relieve the pain?

    Thank you.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    This depends upon the physical examination and your complaints of symptoms as compared to the symptoms prior to the surgery. I would have a patient in your position try an oral steroid first (if you had no contraindications). If poor results and symptoms were increasing, I would consider a new MRI before a suggestion of an injection.

    I use the MRI prior to an injection as the MRI could reveal a small amount of pooling blood (hematoma) and this could be aspirated prior to the injection.

    Dr. Corenman

    Hoosemec
    Member
    Post count: 8

    Hello Doctor

    I have tried a 5 day pack of steroids which had reall no noticeable effects. I would say the sciatica I feel is mild and varies slightly located in the left buttock mostly and not below the knee. Im able to walk about 3 miles a day currently. I’m scheduled for an mri with contrast next week. Which will be about 4 weeks out from the surgery. No real conclusive straight leg test mostly muscle tightness. The mri probably won’t clearly differentiate between scar tissue and disc so early on I understand. My question is if a herniation is found, even if its small, would removing it sooner than later pose any issue ? That would be a third discectomy but perhaps that piece should have come out in the second surgery? I really want to get back to being active. If no herniation is found and its a resultant damaged nerve at least I would know that and could just work through the pain at that point and hope it gets better with time The thought of having another herniation just after an operation and leaving it there would seem like a massive setback. My Back so far has no stability issues.

    Thank you.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    If your symptoms are mild and significantly better than preoperative symptoms, I would give it more time for improvement. Contrast will differentiate recurrent disc herniation from granulation tissue. I would not jump into surgery too quickly based upon your current symptoms.

    A third herniation normally points to a fusion as the nerve gets “battered” if compressed by herniation three times. In your case however, consideration could be given to a repeat microdiscectomy if the new herniation occurs in the immediate postoperative period.

    Dr. Corenman

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