[BillL]

#28373

Dr Corenman:
I have struggled with an L4/5 herniation since 12/17 with a rostrally migrated intraspinal fragment AND a more lateral component. I’m actually a Family Physician and still having problems after surgery 5/2/18. A laminotomy and “very partial” medial facetectomy were performed, as well as an annulotomy behind the laminotomy with use of an angled instrument more laterally to “push” the lateral fragments medially with extraction from within the annular interior. This plus incision of PLL for the subligamentous component. The foramen was said to be “widely patent” afterward.

The first 4 days I had no radicular pain and did not use a pain Rx. Starting day 4 the Celestone used around the L4 root began to wear off and symptoms steadily recurred to at least 70-80% of pre op levels by day 10 or so.

At 3.5 weeks post op I again have pain with sitting, as well as a form of painful arc when straightening up from sitting or lying and then takes a few steps to walk it off. This is the same right “hip” area, thigh, anterior shin as before. Even more odd is similar intermittent symptoms at night (lying on either side and at times supine). At times can trigger the nerve pain either seated or lying supine with pushing the pelvis forward (a type of lumbo-pelvic hyperextension). After walking a bit, standing or walking seem the LEAST symptomatic of positions. Surgeon is very conservative and saying he still thinks due to existing/operative nerve root inflammation but approaching 1 month post-op I’m concerned and a bit miserable (no sensory or motor deficits). Almost done with a Medrol Dosepak with minimal response so far. Post op MRI maybe of limited accuracy this soon, and as an MD, meds that would affect my mental status by day aren’t options. Already had 2 pre-op selective nerve root blocks and the operative Celestone is equivalent to a third.

Any insight and suggestions would be much appreciated.
Thanks

[BillL]

#28396

Dr Corenman:
Please see original question post. As an Addendum, I reviewed the pre op MRI with the radiologist further. He states that there was a pre-op EXTRAFORAMINAL broad-based protrusion as well, which he feels was abutting but not overtly compressing the L4 nerve root. Could this be enough to explain continuing symptoms, especially assuming that all subligamentous and lateral recess/foraminal fragments were cleared? And the radiologist questioned whether the surgeon could have fully reached this extraforaminal area via laminotomy and medial facetectomy….yet clinical significance of this is unclear as well as what to do from here.

Thanks so much, and would really appreciate your expertise on this issue.

[Donald Corenman, MD, DC]

#28401

I apologize for the delay. I was out of the country and answered you but the message apparently did not go through.

Your symptoms seem to be generated by an L4 and not an L5 radiculopathy (“right “hip” area, thigh, anterior shin as before”) as the L4 root radiates to the anterior hip and thigh while the L5 root radiates to the buttocks and posterior thigh down to the top of the foot. See https://neckandback.com/conditions/symptoms-of-lumbar-nerve-injuries/.

If this is the case, your herniation at L4-5 would compress the L4 nerve root in the far lateral position (https://neckandback.com/conditions/far-lateral-disc-herniations-lumbar-spine/). Your disclosure of the surgical approach being posterolateral (the typical intra-canal approach) might mean that the far lateral fragment was missed or that you have a recurrent herniation in this position.

The surgical description that the “use of an angled instrument more laterally to “push” the lateral fragments medially” might mean that the surgeon used this tool “blindly” to push any lateral fragment from the outside to the inside of the canal by reaching around the pars (the lateral boarder of the vertebra). Since this approach is “blind” (use of a tool to “feel” and not “see” the far lateral fragment), I would expect than fragments could have been missed.

Your symptoms of sitting worse than standing pain support a continued disc herniation in the far lateral position. I would consider a new MRI with gadolinium to determine your current “state of the root”.

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.

[BillL]

#28403

Dr. Corenman:
Thanks for the response and no problem about the delay. This lateral canal or extraforaminal area was what I feared. I believe the surgeon went in via laminotomy since he had to also access the subligamentous rostrally migrated fragments as well. And is it possible that even that intraspinal location was a bit “blind” as well? Perhaps missed fragments in that location are less likely since I presume the L5 root more likely to be compressed there and inconsistent with recurrent symptoms?

If a gadolinium contrast MRI is done, how soon would this be accurate enough to distinguish post op changes vs compression whereby a decision to re-operate could be made if pathology seen? (Without going in too quickly yet not waiting many months).

Finally, my surgeon has suggested before that he is a bit uncomfortable with the lateral approach discectomies in general stating less distinct landmarks and potential nerve injury etc.(I’ve seen your online lateral access videos however which look slick). Assuming your suspicion were verified and a far lateral fragment (or bulge abutting the L4 root) persists then would a lateral approach creating a second annulotomy weaken the annulus and predispose to reherniation, right sided collapse and even fusion (the latter being my great fear)? That said, I would think that a lateral approach would be best even if this requires a surgeon comfortable doing so with a minimally invasive dilator system).

Thanks.

[Donald Corenman, MD, DC]

#28407

I believe you are correct in assuming the far lateral fragment is still present. If the surgeon is uncomfortable with the far-lateral technique, then that fragment is most likely still there. There is a small potential problem in that the far-lateral approach (depending upon your anatomy) sometimes requires a small amount of lateral pars removal (2-3mm). If the medial pars was thinned down, the new surgeon has to be very careful to not remove much lateral pars.

An MRI with gadolinium now would be appropriate.

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.

[BillL]

#28412

This makes sense with existing bone removal medially creating a thinner remaining element. He described a laminotomy up to the “shoulder of the L4 pedicle”, “very partial medial facetectomy” with the facet capsule “meticulously preserved”, and a foraminotomy (not sure exactly which structure was thinned to complete foraminotomy?)

With this said, how would a new surgeon determine whether there were enough bone left for a lateral access procedure, and if this is the only way to get to a far lateral disc, how else could it be removed if it were too dangerous to remove more bone? I would hope that it would not be a situation without any surgical options short of fusion?

Thanks so much for the insight as this is a bit complex.

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