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  • rkassam
    Member
    Post count: 8

    About 4 months ago I started experiencing low back pain on my right side. I went to my family doctor who prescribed me naproxen 500mg x 2/ day. After about a month, the pain got better in my back, but then I started to feel severe pain in my right butt, ankle and foot. This pain was accompanied my pins, needles, and numbness in my right foot. It got worse when I laid down, so I had a lot of sleepless nights.

    I went for an MRI and the radiologist results were:

    At l5-S1. there is a large central disc herniation which occupies approximately 50% of the cross sectional area of the spinal canal. This is slightly asymetric toward the right side. This probably impinges on the S1 nerve roots bilaterally, right greater than left within the right lateral recess of the spinal canal.

    At L4-5 there is a large posterior disc herniation centred right paracentral which occupies just under 50% of the cross sectional area of the spinal canal. This probably impinges upon the right L5 nerve root within the right lateral recess of the spinal canal.

    No other significant findings are appreciated.

    My family doctor suggested I see a orthopedic surgeon as my MRI had significant findings.

    I got an appointment for two months later, so I decided to do physical therapy in the mean time.

    I did 6 weeks of physical therapy focusing on the McKenzie protocol. My pain and numbness has diminished greatly. I have intermittent tingling in my right foot with some pain in my ankle on and off. However this pain is quite tolerable.

    My question is that with such a reduction in pain and being able to get through my day, am I still a candidate for surgery?

    The main thing that has me worried is the “centrally herniated disc”. I keeping reading online that this can lead to Cauda Equina. Is it possible that this herniation can get bigger and lead to that. Hence, it needs to be surgically treated now.

    Any input would greatly be appreciated.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8378

    You have two relatively large herniated discs at L4-5 and L5-S1 which have appeared to compress the right sided nerve roots. The typical presentation of numbness, pins and needles and pain accompanied the nerve compression. I will assume you have no motor weakness of the foot dorsiflexors and plantar flexors (you can walk on your heels and toes for some distance without fatigue or weakness).

    You have participated in physical therapy for the last six weeks and have improved significantly. The symptoms now are annoying but not disabling. Again- assuming you have no motor weakness, you can try to continue conservative treatment.

    You have a genetic predisposition for herniations based upon the 2 levels and the large size of the herniations. If the herniations stay the same size and do not enlarge (recurrent herniations), the chance of cauda equina syndrome is remote. Over time, these herniations will shrink down and become less inflamed. There is a chance of recurrent herniation with or without surgery and no one knows the exact incidence of that possibility in your particular case.

    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.
    rkassam
    Member
    Post count: 8

    I have no motor weakness of the foot dorsiflexors and plantar flexors that I have noticed.  I seem to be able to walk on my heels and toes for some distances.

    I realize that surgery is not a 100% cure all as there is always a risk of re-herniation.  So if pain is tolerable why go for surgery.

    However, I am confused about this whole large centrally herniated disc situation.  As this type of herniation is not  as frequent  it is not as easy finding information on it.

    From my research in scientific journals, I have found that a central prolapse is apt to increase in size, which may develop rapidly.  Since this type of prolapse can lead to nerve damage that may not be fully recoverable even after surgery, it maybe advisable to perform surgery in order to prevent progression. That is  it’s better to do the surgery in a non emergency situation were there is no risk of irreversible nerve damage than in an emergency situation.

    As I am not from a medical background, I might just be reading to much into this.  What do you think?

    Thank you for your input.

    rkassam
    Member
    Post count: 8

    bump

    dustingfab
    Member
    Post count: 27

    rkassam post=1273 wrote: I have no motor weakness of the foot dorsiflexors and plantar flexors that I have noticed.  I seem to be able to walk on my heels and toes for some distances.

    I realize that surgery is not a 100% cure all as there is always a risk of re-herniation.  So if pain is tolerable why go for surgery.

    However, I am confused about this whole large centrally herniated disc situation.  As this type of herniation is not  as frequent  it is not as easy finding information on it.

    From my research in scientific journals, I have found that a central prolapse is apt to increase in size, which may develop rapidly.  Since this type of prolapse can lead to nerve damage that may not be fully recoverable even after surgery, it maybe advisable to perform surgery in order to prevent progression. That is  it’s better to do the surgery in a non emergency situation were there is no risk of irreversible nerve damage than in an emergency situation.

    As I am not from a medical background, I might just be reading to much into this.  What do you think?

    Thank you for your input.

    Thank you for posting your last question. Is it better to go ahead with surgery when the current situation is non emergent or wait till you can no longer tolerate the pain and the situation is emergent.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8378

    The answer to your question “Is it better to go ahead with surgery when the current situation is non emergent or wait till you can no longer tolerate the pain and the situation is emergent” is multifactorial. By understanding the risks of surgery with the risks of a non-surgical approach, you can make an informed decision.

    Let us go over the indications for surgery in your case. Motor weakness, cauda equina syndrome and intolerable pain are the indications for surgery. You do not have either of the first two and you are improving with physical therapy so the third one is diminishing. Yes, there is a risk associated with living with the herniations but there is a risk with surgery too.

    The risk of cauda equina syndrome is what appears to be your biggest fear if either herniation enlarges. Yes there is a risk but it is very small. I see only 1-2 patients a year with cauda equina syndrome from large herniations from a total population of about 1000 patients. Surgery therefore depends upon your risk aversion. The risk is 0.2% if you use the above statistics. The risk of recurrent herniation is about 10%.

    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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