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  • jacki
    Member
    Post count: 3

    I had a TLIF at L3 L4 and fusion 4 months ago following a re-herniation having had a discectomy in February 2012. Pre operatively I had back pain but no leg symptoms. On waking from the surgery I had to spend 3 days on bed rest having had a dural tear, throughout this time I noted my foot felt numb.
    Since being discharge my butt, back of my thigh, calf are numb and my foot and toes (except my big toe) are numb and painful as odd as it sounds. I had MRI and CT both indicating no problems and my surgeon suggested that the symptoms were caused by swelling around the nerve root. With no progress I had nerve studies and have subsequently seen another surgeon for review who has said that the studies indicate S1 nerve root damage and that as I have had no improvement it is unlikely now that it will get better. On reading info on the site it does look like nerves can grow back is it likely with no progress what so ever in 4 months that things may improve? I currently walk with a crutch short distances and need a wheel chair for anything other than a few minutes. I would be really glad of any advice.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8409

    Your history is confusing. You had a fusion (TLIF) at L3-4 for a recurrent disc herniation. This herniation would compress the L4 nerve most likely. You note a dural tear during surgery and spent “three days on bed rest”. I do not know why you had to spend three days in bed as the normal length of time for bed rest for dural repair is 24 hours. Do you have any understanding of why three days was necessary?

    The pain pattern you report after surgery sounds to be an involvement of the S1 nerve root. That is uncommon as the root most exposed at the L3-4 level is L4 or possibly L3. The dural tear might have injured the L5 or S1 root if it was a big tear with all the roots displaced and problems were noted by replacement of the roots back into the sack. If it was a large tear, the repair of the dural sack could have also been very difficult.

    Is your problem pain that prevents you from prolonged walking or is it weakness of the leg? Have you had a post-operative MRI to look at the nerve roots? Did the MRI include gadolinium?

    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.
    jacki
    Member
    Post count: 3

    I have re-read the letter TLIF was l4 / l5 sorry! But the surgeon who gave me the second opinion has put the following in his letter.

    “Everything points towareds S1 nerve root injury, which is slightly confusing with a 4/5 operation but on reviewing her scan it does show her to have a segmental anomaly so the actually the operation level was L5/S1 which makes sense now with the area of the injury.”

    I was in bed for 3 days as I had horrendous headaches and vomiting, similar to an extreme migraine. The reason I cant walk far is a combination of increasing pain as I stand or walk and increasing weakness. The surgeon has also put in the letter that I have numbness in an S1 distribution she had weakness of the calf, absent ankle jerk and a positive slump test. I dont know exactly what the MRI included I am afraid.

    I hope that is clearer
    Thanks

    Donald Corenman, MD, DC
    Moderator
    Post count: 8409

    If the operation was truly at L5-S1, this makes more sense. Three days in bed might mean that the surgeon intra-operatively had a massive tear of the dural membrane that was unrepairable and might have unintentionally injured the S1 nerve root. The headache is from the leak of the dural sack. Only when the pressure in the sack can be contained (by either repair of the sack or the CSF fluid being entrapped in a space outside of the confines of the dural sack-pseudomeningeocele) will the headache go away.

    Normally for a massive tear, a diverting drain is used and bed rest for 4-5 days is standard.

    This is a pressure and gravity phenomenon. If you filled a long but narrow water balloon (like the ones that are used by clowns to make balloon animals) and laid the balloon on it’s side, the pressure in the balloon would be low and equal at all points in the balloon. If you took this balloon and then held the end of it up and let it hang, you would see that the bottom section of the balloon would be wider than the top. This occurs as gravity causes the pressure of the water to be greater the further down you go to the end of the balloon.

    The same principle occurs with a dural leak in the lumbar spine. When you are lying down, the pressure in the dural sack is equal from head to pelvis and you have no headache. When you sit or stand up, the pressure in the pelvis region increases dramatically and will cause the tear to leak which tractions the meninges and causes the headache.

    Did you obtain a new MRI? This would give some good information regarding the status of the S1 nerve. Your tests that you noted “weakness of the calf, absent ankle jerk and a positive slump test” are all indicators of an injured S1 nerve.

    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.
    jacki
    Member
    Post count: 3

    Thank you for the reply.

    The only comments made after MRI and CT were that there was swelling around the S1 nerve root, which the original surgeon thought maybe causing my symptoms. Apart from that there was no other comment made. The Nerve Conduction Studies were abnormal and indicative of S1 nerve root damage.

    I guess all these weeks on with the same pattern of numbness and no improvement the Surgeon I sought for a second opinion believes that the damage to the nerve was probably caused during the dural tear. Having been told it is unlikely now to recover – i wondered if there was any way forward.

    I really appreciate your response.
    with thanks

    Donald Corenman, MD, DC
    Moderator
    Post count: 8409

    You do need to give a damaged nerve time to see what kind of recovery can be made (see website under nerve injuries and recovery). If the nerve does not heal, you may be stuck with motor weakness that will not recover. Pain can be modified with medications and if chronic pain is not tolerable, a spinal cord stimulator can be considered. I would not jump into that treatment unless at least six months has passed possibly a year.

    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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