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  • [email protected]
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    Post count: 5

    Hello
    2 weeks ago i had microsurgical decompression of the right L5 root by arcotomy and removal of lig. flavum. On the left side a degenerative cyst compressed the S1 root. This cyst was removed.
    Prior to surgery I had pain in the left bucctocks/thigh and numbness in the calf and lateral part of the left foot. On the right side it was pain in the lateral part of the thigh and upper-lateral part of the calf.
    After surgery the numbness was all gone.
    I had the same pain i the right leg and most of the pain i the left thigh was the same.
    After 5-7 days with progress and ability to walk 100 m without pain I have now experienced more pain and pain when I stand and walk.
    I wonder if this is something to worry about?

    Donald Corenman, MD, DC
    Moderator
    Post count: 8436

    By your description, it sound like you had a bilateral decompression of the L5-S1 level. The description of the cyst removal at left S1 leads me to believe that you have degenerative facets at that level. Cysts can occur from other structures but 95% of cysts are ganglion cysts and are associated with degenerative facets. To carry the association further, degenerative facets are associated with degenerative spondylolysthesis (see that topic discussed in the web site under “conditions”).

    There are four possibilities that could have occurred to cause continued pain. One is that simply the nerves are still inflamed from surgery and over time, they will calm down and the pain will go away. The second is that there is a hematoma (a collection of blood) that is causing compression and again, over a period of time, it will resorb and the pain will recede. The third is that there could be a recurrent ganglion or herniation and that may need to be diagnosed.

    The forth possibility is foraminal stenosis or lateral recess stenosis that may be part of the initial pathology. If your pain occurs with standing and walking and disappears with sitting or bending forward, the last possibility is more likely. Check the section on foraminal stenosis to see if that might fit with some symptoms.

    The x-rays may give some clue. The x-rays need to be taken in the standing position and hopefully, x-rays were also taken in the bending forward and backward positions (flexion and extension). If there is a slip of L5 on S1, this would mean a degenerative spondylolysthesis is present. Decompression surgery (which is the surgery you underwent) can occasionally aggravate this condition but understand that decompression surgery by itself is generally indicated and OK for this condition.

    Let me know what you find out.

    Dr. Corenman

    [email protected]
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    Post count: 5

    Hello again.
    Thank you for your helpful answer to my previous question. I am now 6 weeks after surgery. I have more pain in my right leg than before operation.
    I had at new MRI with contrast 3 days ago. My neurosurgeon has decompressed L5 in the recess 6 weeks ago but on the new MRI it seems as if I have a foraminal stenosis as well as I had a recess stenosis.
    The cyst on the left side compressing S1 was removed but it has unfortunately been regenereted in only these 6 weeks. But the pain form the cyst is not as bad as before operation.
    I had a cortison injecion on the right side aimed at L5 3 days ago and if this injection does not help the doctor will do a new microsurgical op. to decompress L5 in the foramen.
    I know it is difficult for you to say much without you having the MRI pictures but would you recommend a new operation on the right side?
    To me it seems a the first operation on the right side has increased the pressure on the L5 root in the foramen. Does that make sense?

    Donald Corenman, MD, DC
    Moderator
    Post count: 8436

    Were X-rays of your lower back performed? If so, did they reveal a degenerative spondylolysthesis or isthmic spondylolysthesis of the L5-S1 level? See website for more explanation. On the front to back view (the AP or anterior-posterior), was there a significant angulation of L5 on the sacrum? The presence of any of these can indicate the need for an additional fusion of this level to remove the foraminal stenosis.

    Ask your doctor if there is instability of the level. Instability can also lead to a collapse of the foramen and the need for fusion.

    If there is instability, a degenerative spondylolysthesis or isthmic spondylolysthesis of the level, then simple decompressive surgery like you originally had can occasionally cause foraminal stenosis as a side effect of surgery or at least not cure preexisting foraminal stenosis. This is no fault of your surgeon but simply one of the risks of decompressive surgery in the face of instability.

    Dr. Corenman

    [email protected]
    Member
    Post count: 5

    Hello again
    New x rays of the 5 lumbar vertebra did not show any sign of instability or -listesis.
    My neurosurgeon has recommended microsurgical decompression in the foramen of the right L5 root to relieve the L5 symptoms. He will wait and see how the regenerated cyst affecting S1 develops.
    I have had consultation with an ortopaedic surgeon, who has long experience with spine surgery, to get a second opinion. He recommend an laminectomy of the 5. vertebra. He recommend this because of better possibility for decompression and at the same time decompressing the S1 root from the cyst.
    My neurosurgeon finds laminectomy “old fashioned” and with too much risk for “failed back surgery syndrome”.
    So now I have to decide which operation I want.
    Do you find laminectomy too risky?

    Donald Corenman, MD, DC
    Moderator
    Post count: 8436

    From my understanding, you have foraminal stenosis at L5-S1 on the right at the previously decompressed level and a ganglion cyst that has reformed on the left side. The right leg pain is significant and the left leg pain is mild.

    One surgeon has recommended a right sided foraminotomy (which is really a laminotomy and foraminotomy) and the other has recommended a laminectomy which is a bilateral decompression with removal of the entire lamina.

    You state that the x-rays do not note a slip or instability which is good. There probably was no mention of the angulation of L5 on S1 on the front to back (AP) view. This is important as an angulation of greater than 5 degrees can have an adverse affect on outcome with a simple decompression.

    Foraminotomy at the L5-S1 level is a reasonable procedure but has a not insignificant recurrence rate. A full laminectomy is probably not necessary but I do agree that this procedure will have a better chance of a more complete foraminotomy.

    There are two questions I have. First- how insignificant is your left leg pain? The recurrent cyst on the left is bothersome as if you have current left sided symptoms, you might ask the surgeons if that cyst should be addressed. The cyst has the capability of growing larger again and causing problems which might make you consider doing something about it while under only one anesthetic.

    The other is the reason for the foraminal stenosis on the right. Is it from a disc herniation, a spur off the endplate of the vertebra, from a bone spur off the superior facet of S1 or from a collapse of the L5-S1 disc on that side only? The chance of recurrent foraminal stenosis can increase with unilateral collapse or a far lateral disc spur that may be difficult to completely remove.

    “Failed back surgery syndrome” (FBSS) is a poor term as it indicates a failure of surgery but without the reason for failure. If you had a foraminotomy and the foramen re-narrowed, this would be failed back surgery syndrome but the problem could be fixed with another surgery. If the surgery successfully decompressed the foramen but you had continued nerve pain, this would be chronic radiculopathy.

    If either surgeon is technically very good, you would be in good hands with either surgeon.

    Dr. Corenman

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