[leroydog]

#35115

Hello Dr. Corenman,
I find your website to be very informative and helpful. My neighbor mentioned your name after his successful fusion for a severe spondylolisthesis.

I am about 5 and half months in from a disk herniation on 1/5/2022. I was playing basketball and felt an injury after a flexion twist maneuver to grab a loose ball. Over the past several months, I have received multiple opinions, some of which have been conflicting.

Initially, I had all the classic symptoms of a herniated disk, difficulties with bending over, etc. My back pain usually felt R sided midline and primarily in the buttocks. Over time, I noticed mainly tingling, pins/needles in my R foot. A few months in, I began to feel these same sensations in my left foot. Worse with sitting. These sensations have come and gone.

I feel like I have improved somewhat, my back and buttock pain is now a 0 or 1. I’m starting to resume some of my activities like hiking. I am riding my bicycle. I’ve received an initial TFESI R sided on L4/L5 and L5/S1. I had a follow up TFESI for diagnostic and therapeutic means on L5/S1. I did receive moderate relief. My main complaint now is bilateral parathesias in my feet, with right being worse than left. Sometimes it is bilateral, sometimes it is unilateral on the R. probably 80/20 R sided. Sometimes my left side does not bother me at all. My feet feel hypersensitive and sometimes I have mild pain.

Imaging has shown a bilateral pars defect (acquired- diagnosed when I was 18- I played HS football. I wore a boston brace for 6 months. I had a fibrotic union.). Imaging has also shown a very mild spondylolithesis at the level below. MRI also showed a broad based disc bulge on L4/L5 and a small R sided extrusion and herniation on L5/S1 likely contacting the S1 nerve root. Both are fairly posterior in nature. EMG/NCS have been negative.

Since my back and glute pain has improved substantially, I am hesitant to consider back surgery. I am 39 years old. Surgeon A has recommended a decompressive laminectomy with foraminotomy for L5-S1. He seems to think I am fusion candidate as well. Surgeon B has recommended a microdiscectomy at L5-S1. Surgeon B thinks I am a fusion candidate in another 10-30 years or when my slippage gets worse. (I do not have pain with extension). I’m on the fence on what to do. I feel I am doing well with conservative treatment and getting some improvements. Neither surgeon is pushing surgery on me. My fear is that the pins/needles in my foot/feet will not get better without surgery. I’ve met with a neurologist who gave me a thorough workup for peripheral neuropathy which was negative. He advised me to give it time to heal. I am generally in good health and a fit and active patient.

I guess this is a 2 part question….
1. Would the Paresthesias improve with surgery?
2. Would you have a preferred surgical approach?

Thank you,

Luke

[leroydog]

#35116

After reviewing the forum more thorougly, I should also add:

1. I was fairly pain free prior to this event in January 2022. After my initial bracing as an 18 year old, I went on to play 6 years of collegiate and amateur rugby (maybe not the best choice). For most of my adult life, I’ve been very active; triathalons, century bike rides, mountain biking. Last fall, I was hiking up and down the mountains of the Rockies backpacking and hunting with no problems.

2. I have a fairly significant sitting intolerance. Where initially pain was felt in the gluteal region and R hip. I had difficulty with sit to stand. This gradually went away. Now, my foot issues appear to be amplified with prolong sitting.

3. Standing Lumbar flexion/extension x-rays showed no instability. “no evidence of instability during flexion and extension.”

4. MRI report:
a. L4 pars defect with at most minimal anterolisthesis. Some chronic, mechanical fatty marrow changes are present in the L4 pars interacriculari bilaterally. No bone marrow edema.
b. L4-L5: Diffuse disc bulge with questionable mild superimposed, broad-based central protrusion. No spinal canal or lateral recess stensosis. No formainal stensois. Mild facet arthropathy with trace effusions.
c. L5-S1; Small right central disc extrusion/protrusion abutting the traversing right S1 nerve root in the lateral recess without nerve displacement or lateral recess stensosis. No spinal canal or formainal stenosis. Mild facet arthropathy.

5.
a. Surgeon A plan (more specifically): “think the L5-S1 disc his main pain generator. Based on the central location and what appears to be conjoined nerve roots, I would likely do a laminectomy to see if we can unroof this and give him as nerves more space with a foraminotomy and medial facetectomy on the right side. If this did not help him, we would need did do more aggressive things and consideration for a fusion”

b. Radiology/pain management note: ” Imaging shows bilateral S1 nerve root contact and bilateral L5 nerve root contact as well as bilateral pars defect at L4″

Sorry, a couple more followup questions.
1. Would the conjoined nerve roots have a clinical significance.”
2. It seems to be there is some ambiguity in reading my imaging regarding nerve contact, is this normal?

[Donald Corenman, MD, DC]

#35117

This statement is somewhat confusing: “Imaging has shown a bilateral pars defect …. Imaging has also shown a very mild spondylolithesis at the level below. MRI also showed a broad based disc bulge on L4/L5 and a small R sided extrusion and herniation on L5/S1 likely contacting the S1 nerve root. Both are fairly posterior in nature. EMG/NCS have been negative”.

A spondylolisthesis is generally related to a pars fracture (isthmic spondylolisthesis) at the fracture level. A mild slip (spondylolisthesis) at the level below would indicate a 2 level pars defect. Can you paste the radiological report here and we can go over it.

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.

[leroydog]

#35118

Thanks Dr. Corenman,

After reviewing the forum more thorougly, I should also add:

1. I was fairly pain free prior to this event in January 2022. After my initial bracing as an 18 year old, I went on to play 6 years of collegiate and amateur rugby (maybe not the best choice). For most of my adult life, I’ve been very active; triathalons, century bike rides, mountain biking. Last fall, I was hiking up and down the mountains of the Rockies backpacking and hunting with no problems.

2. I have a fairly significant sitting intolerance. Where initially pain was felt in the gluteal region and R hip. I had difficulty with sit to stand. This gradually went away. Now, my foot issues appear to be amplified with prolong sitting.

3. Standing Lumbar flexion/extension x-rays showed no instability. “no evidence of instability during flexion and extension.”

4. MRI report:
a. L4 pars defect with at most minimal anterolisthesis. Some chronic, mechanical fatty marrow changes are present in the L4 pars interacriculari bilaterally. No bone marrow edema.
b. L4-L5: Diffuse disc bulge with questionable mild superimposed, broad-based central protrusion. No spinal canal or lateral recess stensosis. No formainal stensois. Mild facet arthropathy with trace effusions.
c. L5-S1; Small right central disc extrusion/protrusion abutting the traversing right S1 nerve root in the lateral recess without nerve displacement or lateral recess stensosis. No spinal canal or formainal stenosis. Mild facet arthropathy.

5.
a. Surgeon A plan (more specifically): “think the L5-S1 disc his main pain generator. Based on the central location and what appears to be conjoined nerve roots, I would likely do a laminectomy to see if we can unroof this and give him as nerves more space with a foraminotomy and medial facetectomy on the right side. If this did not help him, we would need did do more aggressive things and consideration for a fusion”

b. Radiology/pain management note: ” Imaging shows bilateral S1 nerve root contact and bilateral L5 nerve root contact as well as bilateral pars defect at L4″

Sorry, a couple more followup questions.
1. Would the conjoined nerve roots have a clinical significance.”
2. It seems to be there is some ambiguity in reading my imaging regarding nerve contact, is this normal?

[Donald Corenman, MD, DC]

#35121

Conjoined nerves only occasionally have significance in symptom generation. They are more likely to be involved with surgical decision making.

The L4 pars defects do not seem to be imposing compression on the L4 or L5 roots according to the radiologist but that could be open to some debate.

L5-S1 does have a right sided HNP “abutting’ (maybe effacing) the root but he does not say compression. His conclusion of “Imaging shows bilateral S1 nerve root contact and bilateral L5 nerve root contact” is lacking in a “compression” comment so I cannot interpret this as root compression.

Pain generators are diagnosed by “numbing” the structure (be it root, canal, disc or facet) and gaining temporary relief. See these:

https://neckandback.com/treatments/epidural-injections-and-selective-nerve-root-blocks-diagnostic-and-therapeutic/
https://neckandback.com/treatments/diagnostic-vs-therapeutic-injections/ and
https://neckandback.com/treatments/pain-diary-instructions-for-spinal-injections/

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.

[leroydog]

#35122

Thanks Dr. Corenman,
I did get some relief with the L5-S1. Do you have any comment on the differing surgical approaches? Both of these surgeons are located in Colorado, appear to be well respected. I’m surprised that I’ve received recommendations on two completely different procedures.

Thanks.

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