[Calista]

#32147

MRI results w & w/o contrast
Findings: There is a transitional vertebrae at the superior sacral level, for the purposes of numbering of lumbar vetrebrae this will we referred to as S1
T1-L3 – no significant posterior disc abnormality or stenosis, bony hemangioma noted in the L3 vertebral body
L3-4 there is a broad based posterior disc protrusion, assymetric slightly more prominent on the right than left side. There is a moderate degree of central canal stenosis, Degenerative facet arthrodosis and ligamentum flaven hypertrophy is present. Moderate left and mild right foraminal stenosis is present.
L4/5 there is a left sided posterior disc herniation with extrusion of disc material that extends cephalad along the posterior margin of thevleft side of the L4 vertebral body. There is a moderate degree of central canal stenosis, Degenerative facet joint arthrosis is present. Degernerative endplate signal changes seen, particularly on left side. Moderate right and moderate to severe left foraminal stenosis present.
L5/S- Mild anterolisthesis present, metallic density seen in the disc space. Mild right and moderate degree of left foraminal stenosis, Degenerative facet changes are noted. No central canal stenosis noted, there has been prior bilateral laminectomies at this level.(note it was a 360 fusion, posterior hardware was removed)

Following gandolinium administration, minimal enhacing scar seen along posterior margin of the L5 vertebral body

It has been 6 yrs since my L5/S1 fusion for isthmic spondylolisthesis,and outcome was good. Then significant symptoms of ASD started 15 months ago. At that time the Xrays showed mild retrolithesis at L4/5, MRI had revealed L4/5 herniation L3/4 disc bulge and multilevel spondolytic disease. I have a dextroconvex scoliotic curve of approx 20% eith a rotation as well at L3-5.

I now have axial pain, groin pain, unilateral left sided radiating nerve pain from spine to left wrapping around hip to lateral thigh and shin, with severe relentless spasms in gluteal and quadricep muscles. My leg buckles when walking, and the pain is not relieved by rest, NSAID, muscle relaxants and Percocet 10, all taken together. The muscle spasms are new and after declining with back pain, with some radicular, the pain hit a level where I cannot sleep or function.

Do you think I should agree to a discectomy or extension fusion surgery? I postponed having surgery with first acute episode(s) 14/15 mos ago, but regret now. I have been given conflicting advice, one surgeon said I needed an extension fusion (posterior/lateral) another said multilevel discectomy /hemilaminectomies would suffice.

What surgerical approach gives me the most opportunity to improve? I know I will not have pain free time sans sleep, it is unreasonable. I just want the best possible functional outcome that enables me to go to work hopefully uninterrupted for a couple of years.

[Donald Corenman, MD, DC]

#32156

First, glad to see that you have had a good result from your fusion for your L5-S1 isthmic spondylolisthesis. I would suspect you developed adjacent segment disease (ASD) at L4-5 even prior to your surgery as it is very common to develop a retrolisthesis at the level above even prior to the corrective surgery. You also have degenerative changes at the level above (L3-4) that are not ASD so I suspect that your genetics have much to do with your situation.

You currently have a large disc herniation at L4-5 and central stenosis at L3-4.

(“L3-4 there is a broad based posterior disc protrusion, assymetric slightly more prominent on the right than left side. There is a moderate degree of central canal stenosis, Degenerative facet arthrodosis and ligamentum flaven hypertrophy is present. Moderate left and mild right foraminal stenosis is present. L4/5 there is a left sided posterior disc herniation with extrusion of disc material that extends cephalad along the posterior margin of thevleft side of the L4 vertebral body. There is a moderate degree of central canal stenosis, Degenerative facet joint arthrosis is present. Degernerative endplate signal changes seen, particularly on left side. Moderate right and moderate to severe left foraminal stenosis present”).

I can’t comment on whether a simple decompression or a decompression and fusion are required. It really depends upon angular collapse of any particular level, the amount of rotation of these vertebra, if there is any slip (degenerative spondylolisthesis), the amount of central back pain vs. lateral back and SI/buttocks pain, the degree of the curve above and stability of each segment based upon flexion/extension segments. As you can see, not a simple calculation.

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.

[Calista]

#32162

Thank you for your reply. To answer you to the best of my ability.. hopefully the information below will assist in answering my original question.

1) L4/5 has retrolisthesis of 3mm on X-rays.

2) My spine curves to the left at L3-5 looking at front view of X-ray, unsure where rotation begins but rotation extends to ribcage as it is obvious, as well as my left hip and shoulder are higher. I was 5ft (before disc height loss) and weight fluctuates from 100-105lbs, so easy to see. I had no idea of the fact that I was born with SBO, with transitional vertabrae and Chiari 1 malformation until I started having pain in early 30s. I knew of scoliosis only. I do know all is not uncommon, and do not think it caused my issues in silo, but tend to think abnormal spine alignment is like a car, the longer driven out of alignment, the more issues that result. Especially since I was involved in high impact sports from early childhood until onset of LBP in 30s.

I looked on my operative report from 2011, and at that time it was noted that the interspinus ligament at L4/5 eroded away, and L5/S1 interspinous ligament was removed. Not sure if that has any significance in L4/5 pathology. I was fused without correction of the spondylolisthesis, which report indicates is 8mm.
Also see noted in recent surgeon’s notes “there is significant loss of disc height at L3/4 & 4/5. Nothing exact, but looking at side view of spine, L4/5 looks ~1/2 the height of my L2/3, L3/4 slightly higher, but not by a lot.

3)As with last episode that almost resulted in fusion, I started with more notable increase in general LBP and difficulty standing/walking, then left radicular pain along same nerve distribution to include left hip, lateral leg and tibia pain. Then severe right side back pain that I questioned being a kidney infection because never had pain radiate to the right, and it became relentless.

Then about 2 weeks after the back pain was incapacitating, given being stuck on the floor, suppose muscle spasms in back, started sudden onset of vice like muscle spasms in gluteal and quad muscles, left groin pain, saddle numbness and knee buckling with foot drop. It hit me like a ton of bricks, seemingly out of nowhere when I thought it could not get worse. I realize based upon imaging, that the disc material took its time to impact nerve root it is under.

I have tolerated back pain that lead to modifying my life, unable to travel, drive long or walk my dog, to avoid surgery. It was suggested 15 months ago that I have an extension fusion – but now am getting conflicting opinions. Clearly I would not be asking if I could resolve the conflict in my brain now.

Given I am 46yo, my concern is
1) I think the likelihood, based on my history and comorbid diagnoses of PSA, Sjogren’s and familial pattern hyperextensive joints, is that I will need to address back again regardless of which surgery I decide on.

A) Will not addressing all compressive pathology that would require fusion due to preexisting retrolisthesus and 2 level involvement lead to further interventions at L3-5, that statistically will likely not respond, and have posterior scar tissue issues? Then my life has sucked due to back for 15 months, and although no guarantees, I would like the opportunity to have less of the feeling like something is squeezing/ pressing on my spine, not go to status quo that I accepted to avoid surgery.

B) Which is the a bigger concern?
1) Risk of more surgeries at the same levels and possible permanency of nerve issues or
2) Risk of new ASD which will may result and may happen regardless of what I do?

At 46 yo one thought is I am likely to be healthier now, to endure a bigger procedure. Then the opposing view is fusing will most likely result in another surgery for ASD at a later date.

So in my brain I am kicking one or the other ‘can’ down the road. Which one is more reasonable to kick?

[Calista]

#32164

Sorry, made mistakes
retrolithesis is at L3/4.
Found scoliosis report too
Mild upper thoracic scoliosis, mostly rotational deformity along with left lumbar mild scoliosis with rotational deformity. I was told by surgeon curve was approx 20 degrees.

[Donald Corenman, MD, DC]

#32168

What to do is a question that needs much more information regarding the alignment of the vertebra and what the discs and alignment look above the L3 level. Commonly, there is angular collapse of individual vertebra and unilateral severe disc degeneration which is commonly not discussed by radiologists so take this for what its worth.

You have at L3-4, “moderate degree of central canal stenosis, Degenerative facet arthrodosis” which could mean a rotary listhesis as well as a retrolisthesis as you note. This level should not be ignored and the central stenosis can cause standing lower back pain as well as neurogenic claudication (See https://neckandback.com/conditions/lumbar-spinal-stenosis-central-stenosis/). The degenerative disc disease can also cause lower back pain.

You have a large disc herniation at L4-5 along with probably angular collapse and foraminal stenosis on the left (“Degenerative facet joint arthrosis is present. Degernerative endplate signal changes seen, particularly on left side. Moderate right and moderate to severe left foraminal stenosis present”). This level cannot be left alone either as it is a probable significant pain generator (See https://neckandback.com/conditions/isolated-disc-resorption-lumbar-spine-idr/ and https://neckandback.com/conditions/foraminal-collapse-lumbar-spine/.

So it seems that you nee a two level decompression and fusion above the old L5-S1 fusion.

I cannot comment on the need for other levels included in surgery or the chance of levels above being included in the future. It depends upon activity restriction and what your expectations are.

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.

[Calista]

#32172

Thank you so much.

You confirmed what I already knew. I needed to know for my own sanity. I was forced into the diskectomy surgery. I was in so much pain I could not keep arguing with my surgeon, and the acuity of the situation, I did try to see another ortho, but wait was longer than I could handle.

During surgery, L3/4 extruded under pressure, and MRI missed a second fragment under L5 nerve root. I subsequently sustained permanent femoral nerve damage, but at the time it was unknown whether continued compression from two level disc space collapse, my reflexes were not tested nor did surgeon perform the bending/ flection X-Rays, but he knew of retrolisthesis in 2016, and has been following my spine for 13 years.

Why his decision changed and the multiple tests that he knows were needed were not performed, long story. I am not suing him, but I wanted someone to asess me as I was. I was adament about a fusion, said if insurance says no, I will pay cash. I accept all risks, and how I explained to you why I would want a fusion,I stated all to my surgeon.

All I feared became reality plus worse, because of discrimination, I had nerve damage, posterior scar tissue, told XLIF was best option. I tried to see other surgeons but none would see me until a year post op sithin driving didtance in NJ – My insurer does not sllow me to go out of state or network, no option to purchsse.

I was afraid of continued impingement, and second surgery was performed 6 mos later, as it took 2 months for the surgeon to believe me that I had significant pain and motor weakness, and someone else testing leg and stated to me “you do not have much going on with that leg” – another physician colleague of his had to tell him for him to believe me. It was so demoralizing. I did not stay on nsrcotics, as I wanted to go work, so stopped, but the pain prevents me from being active. The XLIF, I did not yield much, a smidge of movement with knee reflex was noted,as opposed to zero, but ended up with the old and new nerve pain.

I needed a full posterior decompression during the first surgery, and even without I had disc space collapse and aggravation of nerve issues. It resulted in more stenosis at L3/4 , same degenerative changes, now bilateral groin pain, full saddle anesthesia, spasms returned albeit chronic misery vs I need a gun misery, and the patellar reflex, only care because of associated weakness and balance issues. I still have the pain radiating around left hip to lateral spine crossing over tibia. Cannot stand up straight, walk much on left leg, both feet go “to sleep” when sitting for more than a few minutes. So now almost 2 years later and most days are spent standing, leaning on my counter top on right leg like a flamingo, because the only other comfortable position is laying down on my Tempur-Pedic GrandBed. I stretch and work on quads and core but cannot do enough because pain exasperates and then is relentless for next 24-48hrs.

I tried to go back to work, but cannot, and am now treated like a FBSS that is my fault by other surgeons. I do not state what happened because no one would treat me at all. Had new MRI w/wo contrast, and in addition have residual disc herniated behind both new cages, and every level is either antero or retro listhesis of 3mm (except original is 8mm) including L2/3 which may or may not be causing issues, height looks fine, no stenosis noted or other pathology. However I am not a fan of minimslky invasive, as MRIs often do not show issues, at least all mine were underaporeciating vs what was visualized intraoperatively. And surgeons now want a CT myelogram, my insurer does not want to pay for after $5000 NRI on Tesla 3 machine, which was probably overkill.

I am going to lose my house, and everything I worked for I am losing, have no help and am stuck until someone realizes that untreated pain, and disability for 2 yrs with zero income, no amount of psychological help will mitigate the fact that I have blown through my savings, money tied in house is tied because I cannot work, and I need to move with nowhere to go, no plan, while patiently waiting until someone that practices at least an hour away which is a painfully long drive for me now, to prevent going to previous surgeons’s friends/ colleagues, obtains the CT and thinks that posterior decompression, and anything else thst might be wrong is worth the risk.

I worked with medical experts my entire career, my father was a physician, and I had a complete respect and admiration for the profession. Now I am so conflicted after being in my situation. I obviously know better than get involved in malpractice, let along mention. But I was called for jury duty, and the practice that was evaluating me immediately thought I was asking for disability certification, and even when explained that I cannot drive 2 hrs rountdtrip to sit for 8 hrs, no one called me back regarding note request. I got elsewhere, but the discrimination over the past 2 years, had me questioning myself – and avoiding healthcare professionals because after being dismissed and symptoms not taken seriously starting in March 2018.

I knew bias exists, but knoe first hand why women (or obese, non caucasian, or patients with psychiatric dx) either are treated subpar or avoid treatment due to previous discrimination. I knew the prevalence in cardiology and ER visit treatment of women, as well as derogatory mnemonic for galbladder disease, the source of the term hysterectomy, one if the most overperformed operations, but living it vs knowing it, is miserable.

But thank you for giving an honest opinion, based on the facts presented. I know not all were as I did not have them, but at least hearing it was a reasonsble decision, restores some of my sanity after reading every article published on the topic ;)

Thank you again, you provide a great service to patients. I wish I had found your website during the 10 day debate with my surgeon over the first surgery. 20/20 hindsight is brutal.

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