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  • Tiku311
    Member
    Post count: 4

    I’m a 35 year old cardiologist and unfortunatley have a h/o back surgeries. The first was an L5/S1 lami/discectomy on the right in ’97 with immediate relief of symptoms. I did well for over 10 years until ’08 at which time I developed left sided back and leg pain. I underwent an MRI revealing a left sided L5/S1 herniation. The pain distribution was different on the left then the right but I assumed that was due to some degree of asymmetry in my dermatomal distribution. I dealt with the pain conservatively for 3 years (including a couple of epidurals with minimal relief). Finally the pain progressed and I finally had surgery in 6/11 with a left sided L5/S1 microdiscectomy. Since surgery I’ve had ongoing radicular left leg pain though my back pain is significantly improved. I had an epidural in 10/11 with some improvement but now the pain is back. Interestingly the pain distribution now includes the prior area before the surgery but also new areas in my left leg as well. The pain is not as severe as it was before surgery but it is now almost constant and especially when I sleep on either side. Unfortunately due to the constant symptoms and difficulty sleeping, I’m considering a repeat procedure (even “laser spine” surgery for FBSS). Please advise.
    Any assistance would be greatly appreciated.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8378

    To reiterate your history, a microdiscectomy L5-S1 right in 1997 with good relief. 2008 noted development of left lower back pain and leg pain and an MRI noting a left herniation at L5-S1. Conservative care insued for three years with a microdiscectomy on the left on 6-2011.

    After surgery, the back pain improved but the left leg pain has not. An epidural two months ago helped somewhat. The pain is not as severe as prior to surgery but is now constant where before it was intermittant. Pain now occupies both the old pain pattern and a larger distribution area but only in the left leg. Is that correct?

    Is the pain constant but varies with position? Is the pain worse with standing and walking but improves with sitting or the reverse? Does the pain have the same previous quality or is it changed? Is it more of a burning quality now? Do you have any weakness?

    Pain that doesn’t improve after a microdiscectomy could be from many factors. A hidden fragment that was not removed during surgery, a space occupying hematoma that formed after surgery, a recurrent disc herniation (these can occur just getting up the day after surgery), a foraminal collapse or chronic radiculopathy (see website) are just some of the possibilities.

    Have you had an MRI post-operatively with gadolinium? This would be one of the most useful initial tests. Make sure the MRI is performed on at least a 1.5 tesla machine or better yet, a 3.0 tesla machine.

    “Laser spine” surgery in my opinion is a gimmick that would not help. The laser is simply an ablation device that destroys tissue using heat and should have miminal use in the spine. You need a good work-up to determine what the pathology is and no surgery unless there is reason to operate.

    Hope this helps.

    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.
    Tiku311
    Member
    Post count: 4

    Thanks for quick reply!
    Your summary of my problem is spot on.
    I did have an MRI with gadolinium 2.5 months post op and it revealed postoperative changes around the nerve root. There was also mention of some osteophytic changes but no mention of residual or new disc herniation. No mention of foraminal collapse. I know that a foraminotomy was not performed at the time of surgery (and perhaps it should’ve been since it’s the second surgery on the same level).
    The pain I have now is worse primarily when I sleep on either side but left greater than right. It is also bothersome when I sit. It improves with standing and feels the best when I walk. It is a burning and cramping type pain and similar to the prior pain but, as mentioned before, more constant, less severe, and involving a larger distribution. I also tried both neurontin and lyrica with some relief but the drowsiness made work difficult so I stopped both.
    Of note, I also have some mild paresthesias in my right foot which are new.
    I attempted to exercise last week and after 30 minutes on an elliptical machine I developed numbness of both great toes which is a new finding. My preop numbness was primarily in my 4th and 5th right digits. Fortunately there is no significant weakness I notice in daily activity but a physical therapist noted reduced strength in my left glut.
    I’m approaching the 6 month anniversary of the surgery and don’t feel like celebrating.
    I don’t want another procedure but need to find an explanation as to why I feel the way I do.
    Thanks again.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8378

    Pain that improves with standing and walking is most likely not from foraminal stenosis or lateral recess stenosis. Burning/cramping pain is associated with chronic radiculopathy, more so if night pain is part of the symptom complex.

    A selective nerve root block (lidocaine with steroid) can be helpful for symptom relief and diagnosis. If there are no compressive elements and the root is swollen or surrounded by inflammation, there may not be any surgery that can help. It may be worthwhile to get another pair of neuroradiologist eyes on the MRI.

    If this turns out to be chronic radiculopathy, you may be a candidate for a spinal cord stimulator. You can have a trial (it is an outpatient experience) and if you like it, have the device implanted. There are occasions that if this is chronic radiculopathy, time with be helpful to reduce pain but that is not a guarantee.

    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.
    Tiku311
    Member
    Post count: 4

    Thanks for the help.
    I’ve also recently been diagnosed with a central C4-C5 herniation without nerve root involvement but some degree of central cord compression. I’m having bilateral radicular arm pain which is improving slowly. However I’m also having some mild paresthesias in the right leg which is new as my only pain before was the left leg. Have you seen cases of cervical cord compression causing radicular symptoms in the lower extremities?

    Donald Corenman, MD, DC
    Moderator
    Post count: 8378

    Cervical cord compression can cause myelopathy which in turn can cause paresthesias in the upper and lower extremities. There should be more symptoms than these paresthesias however. Imbalance, some loss of fine motor control, possible electric shocks down the spine and other symptoms could occur. If the paresthesias increase with neck extension, this could be myelopathy as the spinal canal narrows with extension and cord compression increases.

    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.
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