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  • MASpinept
    Participant
    Post count: 15

    Hi dr. Corenman,

    I have posted a few questions throughout my surgical journey, i am in the process of scheduling a long distance consult with you, i’m just waiting to hear back from your office. I look forward to getting your opinion on everything. IN the meantime i was hoping you could offer an opinion.

    I am 16 months out from L5 S1 tLIF for recurrent herniation causing leg weakness, also i had an l5 pars fx and spondy which developed from the 2 pervious laminectomies that were also done) urgently) for a disc herniation that caused footdrop. My symptoms improved at about 8 months post the TLIF and i started ramping up my activity at that point. Unfortunately shortly after doing so many of my pain and nerve sx became more noticeable and have continued to get worse and worse. I started pushing my surgeon’s office for imaging and they discovered i am not fused.

    I have had 2 Cts in the past 5-6 months and i am not fused at all in the posteriolateral areas and apparently i am 80% in the anterior, but not anterior to the cage. The radiologist calls this fused area “minimal” but my surgeon said it is enough. Both radiology and surgeon agree posterior is not fused.

    I was under the impression that i needed a revision but now i am being told that all my symptoms are from my 3 surgeries and are related to scarring and nerve damage of my cauda equina (which i didn’t realize was ever damaged). I am not ready to give up. I am hoping you can help.

    I find it hard to believe that the spine pain at the end of the day and into the night is all related to nerve damage. It feels like bone pain and it radiates to my tailbone and spreads into my pelvis and it’s intensity is dependent on how active i have been during that day. Below is the CT report. Thank you!

    Indication: Assess fusion status post lumbar spinal fusion.

    Technique: Helical CT of the lumbar spine was performed according to routine
    protocol. The helical data set was reformatted in the sagittal and coronal
    planes. Additionally a 3-D model of the data set was performed at an
    independent workstation.Dose reduction techniques were utilized including mA
    and/or kV adjustment.

    COMPARISON: CT lumbar spine from 7/9/2021.

    Findings:

    Hardware: Fusion construct at L5-S1 with bilateral transpedicular screws and
    connecting rods. Intervertebral spacer noted at L5-S1. No perihardware
    lucency to suggest loosening. Screws appear to be in the expected location.
    Hardware appears intact.

    Osseous Fusion: At the left L5-S1 facet joints, there is marginal bony
    bridging, similar in appearance to prior CT. No joint gas identified suggest
    excess motion. No right posterolateral osseous union identified.

    At the L5-S1 disc space on the right, there is minimal bony spicule
    formation, similar in appearance to prior study, which may span the height
    of the disc space. No intervertebral disc gas to suggest excessive motion.

    T12-L1: No significant central canal stenosis. No neuroforaminal stenosis.

    L1-L2: No significant central canal stenosis. No neuroforaminal stenosis.

    L2-L3: Mild bilateral facet arthropathy. No significant central canal
    stenosis. No neuroforaminal stenosis.

    L3-L4: Mild right facet arthropathy. No significant central canal stenosis.
    No neuroforaminal stenosis.

    L4-L5: Shallow concentric disc bulge with mild left facet arthropathy. No
    significant central canal stenosis. No neuroforaminal stenosis.

    L5-S1: Status post right partial hemilaminectomy and medial facetectomy. No
    significant central canal stenosis. No neuroforaminal stenosis.

    The imaged upper sacrum and upper iliac bones appear unremarkable.

    The imaged retroperitoneum appears unremarkable.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8193

    It is very common to have some initial improvement from a TLIF decompression and fusion but have symptoms “show up” 6-8 months after surgery due to pseudoarthrosis. (“My symptoms improved at about 8 months post the TLIF and i started ramping up my activity at that point. Unfortunately shortly after doing so many of my pain and nerve sx became more noticeable and have continued to get worse and worse. I started pushing my surgeon’s office for imaging and they discovered i am not fused)”.

    Generally, if you have local back pain (central pain-not unilateral) some time after fusion is unsuccessful, this pain is generated by the spine itself (the non-united bone fragments press together). Unilateral pain at the L5- S1 level can be either pseudoarthrosis or nerve related. Pain in the SI joint or buttocks on one side more likely is nerve irritation.

    How would you characterize your pain in percentage lower back to leg and how does it change with activity?

    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.
    MASpinept
    Participant
    Post count: 15

    Well it’s variable; I would say the leg pain and back pain can exist together or apart and aggravation and pattern is not consistent between the two. The right leg I have frequent nerve pain from buttocks to toes, mostly L5 and S1 (and this is chronic damage from the multiple injuries and surgery, I never expected that this pain would go away even after the fusion). When I am active I get symptoms more on the front of my leg and into my big toe, sometimes this happens on my right toe as well but does not follow such a specific pattern on the left leg.

    For the back pain, it’s always best in the mornings and by about 2-3 pm it starts getting worse, evening and night time are very uncomfortable. I try to walk 1-2 miles daily even now, despite having had to peel back most of my activities. At first I feel fine during exercise and then I start getting pain that feels directly in my spine, sometimes it will spread out like a cross but not always. Lately I get very specific sharp pain that feels very close to the top left screw, this is definitely bone pain and it doesn’t radiate too far from that spot. Immediately after being active my back feels locked up. Once I stop moving and then as the day or evening go on my back just aches and aches, it feels like the area around the screws, sometimes it feels hot and inflamed. I can feel the screw heads very easily when feeling my back, it hurts to lay on hard surfaces so that is how I am able to tell where they are, if that makes sense.

    The night when the pain is very bad it feels like a combo of pain in my entire lower half of my body. It feels like throbbing pain in my spine that goes down to my tailbone, then it will involve my hips and radiate down to my legs as well, but the leg pain associated with this isn’t the specific nerve pain, but sometimes that specific nerve pain is there at this time, as well. Additionally I get a lot of muscle twitching and restless leg feelings (also something I am not expecting to ever go away).

    The worst activity is running, which I have stopped doing since the summer. Although now horse back riding, specifically posting at the trot, has become very painful and almost not worth it, I have basically stopped that as well. Peloton is the only exercise that doesn’t cause a lot of discomfort after.

    Sorry this is so long winded, just trying to specific with the pattern of pain!

    Donald Corenman, MD, DC
    Moderator
    Post count: 8193

    Your pain pattern sounds like bone pain (pseudoarthrosis) but if a solid fusion is present, it could be hardware pain. The CT scan will be very important to review as it sounds like you have lack of fusion. You might need an ALIF to repair your spine.

    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.
    MASpinept
    Participant
    Post count: 15

    Yeah, I look forward to speaking with you more about it. I believe I have a tentative appointment for a long-distance consult with you next week, just waiting to hear back from the office to confirm. I’m interested to see your thoughts and interpretation of everything.

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