[amoresi]

#25461

Hi Dr. Corenman. After 2 previous decompressions at L5-S1, both on the right, I had a single level TLIF at the same level in August, 2015 as a result of the disc collapsing after the second decompression. I did relatively well after that surgery for approximately 15 months. In December 2016, I began having pain in my right leg again. An MRI revealed severe foraminal stenosis at L5-S1 from bone spurs . As the pain worsened, I finally had a decompression in March 2017. During that surgery, my surgeon also removed my fusion hardware as he said I was fused. The surgery relieved the right leg pain, but 4 weeks I started having pain on the top of my left foot. As more time has passed, I also now have pain in my left buttock and back pain. I had none of this pain after my initial fusion surgery. He has discharged me from his care as he says my CT scan shows solid fusion and MRI shows no nerve root compression that would explain the leg pain. I feel he’s only relying on imaging and not taking the clinical symptoms into consideration. I don’t feel it’s a conincidence all these new issues have shown up after hardware removal. I’ve read that imaging can not evaluate fusion successes 100%. Is that accurate? What should I do? My symptoms seem to be getting worse weekly, and no other surgeon around here will even evaluate me since I’ve had surgery within the last year.

[Donald Corenman, MD, DC]

#25466

I cannot understand why another surgeon won’t evaluate you as we do commonly for patients who have been released from care but have continued pain. You might still have problems at that operated level (pseudoarthrosis, new bone growth causing nerve compression, seroma) or an adjacent level that is painful. If you have not have had a CT scan, then fusion status is not certain.

First, get the radiological report dictated by the radiologist and read what it says. The gobbledygook might be hard to understand so you can cut and paste the results here.

If you can’t get someone to look at you, for a fee I have a long-distance consult service where I review all past consultations and images along with a 5 page history form that you fill out and then talk to you over the phone for about 20 minutes. All follow-up calls are free.If you do need help and schedule an appointment, the fee for the consultation is deducted from the new patient office visit.

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.

[amoresi]

#25469

Thank you for your reply. It’s extremely frustrating. The staff asks if I’ve had previous spine surgery. When I tell them I had a recent decompression and hardware removal on 03/29/2017, I’m always told Dr. so and so doesn’t see patients so recently removed from surgery. And that they usually don’t see patients with previous surgery until after one year out. If I can’t get a physician to evaluate me, I may just proceed with the long distance consult with you. If refreshing that a surgeon is as accessible to patients through a medium like this.

Below is from the radiology report of the CT scan I had on 05/08/2017. This was after surgery but before the symptoms really started getting bad.

FINDINGS:

Patient has bridging osteophytes at the SI joints. Since 3/25/2017,
the fusion hardware has been removed at the L5-S1 level. Patient is
status post L5-S1 facetectomy. There is homogeneous soft tissue
density material at the site of the facet joint extending to the
dorsal margin of the vertebral body. This may all be fibrous tissue.
The L5 and S1 levels appear to be fused across the intervertebral disc
space. L5 level is normal in AP diameter. L4-5 has mild disc bulge. L4
level is normal in AP diameter. L3-4 is without disc herniation or
stenosis. L3 level is normal in AP diameter. L2-3 shows no disc
herniation or stenosis. L2 level canal is normal. L1-2 shows no disc
herniation or stenosis. L1 level is normal.

IMPRESSION
IMPRESSION:

Interval removal of fusion hardware from L5-S1 level. L5-S1 level
appears fused. For further evaluation of the right L5-S1 area, MR with
and without contrast might be considered. Plain CT cannot distinguish
between extensive fibrosis and intermixed disc herniation.

But a plain xray says the following (“without evidence of complete bridging osseous fusion”)

L5-S1 interbody fusion with associated laminectomy is again
appreciated without evidence of complete bridging osseous fusion.
There is no evidence of acute fracture or significant listhesis. Mild
osteoarthritis in the region of the thoracolumbar junction and at
L5-S1. Cholecystectomy clips. Pelvic phleboliths.

This is the most recent radiology report from an MRI my pain management physician ordered on 05/20/2017.

HISTORY: Back and left leg pain 6 weeks following hardware removal from
the lumbar spine.

Routine imaging was performed with and without 16 cc of gadavist.

COMPARISON: X-rays done March 15, 2017 and MRI January 2016.

There has been interval removal of the pedicle screws at the L5-S1
level. There are residual postoperative changes in the posterior aspect
of the lower lumbar spine and subcutaneous tissues. There is normal
alignment of the vertebral bodies. There is no fracture or bony
destructive change or significant marrow edema. Disc space narrowing
with disc desiccation is seen worse at L5-S1 and L4-5. The rest of the
vertebral bodies and disc spaces appear normal.

Axial imaging from T12 down to L4 are normal.

L4-5: Mild bulging and facet hypertrophy without canal compromise.

L5-S1: There appears to be a disc spacer to the right of midline. The
pedicle screws and been removed. There is a fluid collection projecting
over the right facets at L5-S1 with some surrounding enhancement but
the adjacent bone and bone marrow signal appears relatively normal.
There is also infiltration of the subcutaneous tissues bilaterally
following pedicle screw removal without any additional fluid collection
seen. There is a small amount of perineural fibrosis with enhancement
on the right with a right laminectomy defect. There is no recurrent
disc herniation significant spinal or foraminal stenosis at any level.
The epidural space on the left is entirely normal and there is no left
foraminal encroachment.

The sacroiliac joints appear to be normal and well preserved. There is
no edema present.

There is no epidural fluid collection hematoma or abscess suspected.

The conus is of normal caliber and signal intensity.

There is no other abnormal enhancement following gadolinium

I do recall before my most recent surgery the surgeon said that if when he got in there and if I wasn’t fused, he was going to do in-situ fusion by adding bone graph like a posterolateral fusion and replace the hardware with larger hardware. I read his post-op report. It has no mention of inspecting the fusion mass itself. Only that the hardware was not loose, and had excellent purchase when backed out. Given my condition after hardware removal, is it still possible to go back in and add additional bone graph to the outside of the posterior spine to augment the fusion, and re-instrument either unilaterally or bilaterally to add stability?

[Donald Corenman, MD, DC]

#25474

The CT scan can “see” into the vertebral body where the X-rays have so many overlying shadows, it is difficult to definitively determine fusion in many cases. If the radiologist notes solid interbody fusion, you most likely have a solid fusion.

There appears to be a small amount of fibrous tissue (as to be expected) around the right nerve root (“There is a small amount of perineurial fibrosis with enhancement on the right with a right laminectomy defect. There is no recurrent disc herniation significant spinal or foraminal stenosis at any level”).

If you have a solid interbody fusion, you should need no additional bone graft on the sides (posterolateral gutters).
You understand that I am looking through someone else’s eyes when I look at any report and not the actual images but assuming the report is accurate, you have no stenosis or instability. You might have chronic radiculopathy (https://neckandback.com/conditions/chronic-radiculopathy/).

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.

[amoresi]

#25479

Thanks for your reply doc. A diagnosis of chronic radiculopathy would be easier to accept if the pain I was having was in my right leg. Both of my previous decompressions prior to my fusion were for herniations that were compressing the right S1 nerve root. And the recent decompression post fusion was for hetertopic bone that was growing from where the right facet joint was removed during my TLIF and was impacting the descending right L5 nerve. I’ve never had any left sided nerve root compression and only developed pain in my left leg since after the bilateral hardware removal and right sided decompression. Interestingly enough, I also had an EMG/NCV test in early May that didn’t reveal any radiculopathy originating from the lumbar spine, but a finding of peroneal neuropathy on the left leg was present. Not sure I how reliable that is given that the pain in my left leg proceeded my recent lumbar spine surgery and I also developed some nerve pain in the left buttock area.

[Donald Corenman, MD, DC]

#25490

Peroneal neuropathy is not an uncommon cause of leg pain. See https://neckandback.com/conditions/peroneal-nerve-entrapment-at-fibular-head-knee/.

This disorder can occur from surgical positioning as you have to lie on a padded surface to have surgery and occasionally pressure can occur over the outside of the leg to irritate this nerve. If you can percuss the outside of your leg right below the knee sharply with your fingers and get an electrical “zap” down your leg to your foot, you have a “Tinel’s sign” and an active case of peroneal neuropathy. This could be the cause of your leg pain although this disorder normally does not cause buttocks pain.

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.

[Author]

Posts