[ebchnd]

#30224

Hi Dr. Corenman, I was diagnosed with a severely herniated disc on March 2, 2019. A CT revealed a large right paracentral disc extrusion at L5-S1 causing severe right lateral recess stenosis and moderate canal stenosis. This has manifested as severe muscle weakness to the right gsatrocnemius

I had significant pain the first day, and have been on a steady diet of prednisone (now complete), ibuprofen, and gabapentin. After the first weekend, I generally don’t experience constant, significant pain, however the pain is triggered when doing straightening my leg (bending forward without bending knees, moving from seated to standing, etc.).

I realized on the second day of the extrusion (March 3rd) that my limp was caused by severe muscle weakness in my right calf (unable to do a toe raise), rather than the numbness and tingling that I had been experiencing. I have since visited my primary and had two (very reputable) surgical consults while waiting for an MRI to be completed.

As of today, the recommended approach is to try epidural steroid injections and evaluate for possible surgery. I’m of the mind that surgery is inevitable if I want the best chance at motor function recovery, and have serious concerns about the timeframe I’m working against.

I’ve read multiple studies that in some way discuss the connection between timeline and muscle weakness recovery, and while there’s no definitive answer (other than “sooner is better”), the consensus seems to be less than 8 weeks, and possibly even 4-5 weeks. At the same time, I’ve read anecdotal stories of recoveries well after this timeframe.

I was hoping to get your perspective on this, and any suggestions you might have to expedite surgery vs. the epidural route.

Thank you.

Eric

[Donald Corenman, MD, DC]

#30228

I am currently engaged in a preliminary study to determine what percentage of patients recover strength with quick surgery, delayed surgery or no surgery at all. I can tell you anecdotally that the sooner you have surgery, the better chance you have of recovery. I would say that 1-2 weeks after loss of strength is the important time period but that might change with analyzing the data. I can tell you generally that less than 50% gain full motor strength without surgery and about 80% gain useful motor strength with surgery in the early period. The quicker to surgery, the better should be the logo with motor weakness.

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.

[ebchnd]

#30240

This is very insightful, thank you Dr. Corenman.

You noted that anecdotally about 80% gain useful motor strength with an early surgery. With the full understanding that this is based on anecdotal information, Do these results include those with more severe cases (MRC:2+) and/or with lateral vs. central extrusion?

I understand from the literature that severe gastrocnemius motor loss tends to have reduced outcomes vs. less severe (MRC:3+), and I also understand that lateral vs. central extrusion can also be an issue, but I’m trying to get a better sense of what these outcomes are. Do you still see this ~80% result among this group?

Thanks,

-eric

[Donald Corenman, MD, DC]

#30241

Normally, the extent of typical neurological compression weakness occurs at a 4/5 on a 0-5 scale. That means the muscle can contract and offer some resistance but fails under significant load. A 4/5 quadriceps weakness (muscle which straightens the knee) could support you using “timid” steps but would buckle with ascending or descending stairs or getting up out of a chair.

I surmise that much more dense weakness (2-3/5, no resistance under load) has a higher chance of permanent weakness even with surgery and needs a quicker time to consider surgery than the others. I have not found that the position of the herniation matters however an extruded herniation that wedges between the pedicle and nerve root has a higher chance of causing motor weakness.

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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