AhernMemberSeptember 9, 2013 at 10:49 pmPost count: 3
Hi Doctor – I had a l5/s1 fusion two years ago for sponylothesis. Two months ago I suffed a 18×11 mm herniation at the l4/5 level. Extruded, but I do not think a fragment.
Pain in buttocks (both sides) and back and burning in penis. Sometimes left foot sensations and leg spams.
Surgeon who performed fusion surgery wants to do a microdisctomeny, which he said will help get me back to preherniation pain. More conservative surgeon says herniation pain will improve with time and do not do surgery. Didn’t say there were any downsides, but said that is what he would do if it were his back.
I am only 43 years old and father of 3 young children. There is not much disc left at l4/5 and I have ddd at l4/3. All I can think about is 10 years from now and a triple level fusion.
What do you think the chances of this hernation dissolving, shrinking on its own so that it is not symptomatic or do you think my fears will become reality?
Thanks in advance.Donald Corenman, MD, DCModeratorSeptember 10, 2013 at 6:21 pmPost count: 8468
You do have a dilemma in decision making. I will assume that you do not have any motor weakness (especially of the tibialis anterior or the gluteus medius muscles-see website under “conditions’; “nerve injuries and recovery” then “symptoms of lumbar nerve injuries”).
This weakness will be discovered in a thorough physical examination which I assume you have already underwent. If you have motor weakness, in my opinion you need surgery much sooner than later. I will also assume that you do not have cauda equina syndrome (see website) as that disorder is also a surgical condition. If you do not have either condition, you have to consider the benefits and risks of waiting.
The benefits of waiting are that you avoid another surgery and the potential risks of that procedure. The risks of waiting are that this herniation is quite large and causing compression of the nerve root but not enough to cause motor weakness at this point. You have a chance of developing chronic radiculopathy (see website) which is a permanent condition of pain generation.
The problem is at this point, there is not a study that can answer two questions. How long do you have before surgery would be ineffective to prevent chronic radiculopathy? What percentage of patients in your situation will develop chronic radiculopathy? I am gathering data to write this paper but it will be some time before it is out.
Unfortunately, you do have the genetic traits that promote degenerative disc disease but that does not mean that you are going to be a fusion candidate in the future. Read the sections regarding back care on this website and find a good Pilates instructor who can educate you in core strengthening.
Dr. CorenmanAhernMemberSeptember 11, 2013 at 3:12 amPost count: 3
Thanks Dr for responding to my post so quickly. One more question, what are the chances the herination will dissolve on its own? Does that frequently happen or myth? I have read that the big ones typically dissove, but unable to get any concrete answers.Donald Corenman, MD, DCModeratorSeptember 11, 2013 at 9:56 amPost count: 8468
The disc herniation can reduce in size over time. This has a higher likelihood to occur if the herniation is very hydrated (full of water) which can be noted on MRI of high signal on T2 images. This water can be absorbed somewhat quickly and reduce the size of the compressive force. The herniation can also migrate if it is a free fragment and exit through the foramen. It will eventually “get stuck” on the surface of the psoas muscle and cause no harm.
These possibilities are balanced by the fact that this fragment can also get “stuck” in its position and continuously compress the nerve. This can cause chronic pain in the nerve root. I had just seen a patient today who had a herniation six months ago. She elected to wait and had improvement but continued leg pain and still has a sensitive nerve root.
There is no right or wrong answer to surgery for herniated disc without motor weakness. I think the die is cast if there is motor weakness (surgery is needed).
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