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Good evening-
On June 7th,2017 I underwent a Mirco-d at L4/5.
For the past 23 years my chief complaint is low back pain with pain runnning across my left buttock and running from my left hip to knee. Maybe once or twice a year I might have a lightning bolt run down to my left foot. I can always tell you when it’s going to rain since the pain in my hip and knee gets much worse.
Originally my Neurosurgeon wanted to do a ALIF but BC/BS would not approve the anterior or oblique approach without a failed posterior approach. At least that’s what my surgeon told me.
When we discuss the micro-d my surgeon had a resident with him and was explaining the facetecomy and that the plan was to remove no more than 30% of the facet. He explained if he removed more than 50% of the facet there would be a good chance they would leave me unstable. I returned for a follow up 8 days post-op to have the staples removed. Also, we discussed suturing since it would would only be approx a one inch incision. Well I woke up to find I had a 5 inch incision and a pile of staples closing my surgical wound. During my follow up I asked about what percent of my disc was removed and he did not know and then I asked how much facet was removed and was told “easily 60%”. I reminded him of our discussion that removing more than 50% could leave my spine unstable. He stated he had to remove more to get the end result we were looking for.
I understand that I am not very far along in the healing process but I still have leg pain that pre-op was at an 8 most days even with the use of “heavy” narcotics. Since my surgery my leg pain is worse and different. The pain is sharper than before surgery and now extends below my knee. My leg pain is in my left groin, left knee and shin and calf area. I have tried heat at the site of the pain in my left leg, ice packs at the site of the pain and Bio-freeze at the pain sites. I have only used ice packs on my incision site. And I get no results from any of the above therapies.
My questions are as follows:
1) Are my expectations unrealistic in thinking my leg pain would be gone or better and not yet be 1 month post-op?
2) With my chief complaint being low back pain will the micro-D do anything to help with my low back pain which is my biggest generator of pain or will this procedure only address the pain in my left leg? Because my low back pain is worse and I realize some of this is due to the traum of surgery.
3) What type of post-op imaging would you reccomend to confirm how much disc material and how much of the facet was removed. Would it be out of order to ask for a copy of the surgical notes for myself to have or should that be best for a different surgeon to request the surgical notes? I have a file several inches thick with reports of all MRI’s, CAT scans, discogram (torture) and basically anything to do with my low back.
4)How soon after L4/5 micro-d would you suggest starting physical therapy. I was told prior to my surgery the nursing staff would get me up and do some walking same day of surgery. That did not happen but upon being released I started walking short distances and my left leg has gone out on my several times all but one was I able to catch my self on furniture and the other time I fell to the floor. After reporting this to my surgeons PA he prescribed a walker that I use. What I mean by going out is while walking it step using my left leg and it feels as if there is nothing there and my leg buckles and I fall.
As a background I have DDD, stenosis and arthritis. I have 2 prior cervical fusions almost to the day 2 years apart. After my first cervical fusion there was no evidence of a rupture the disc above or below. As a matter of fact the surgeon that performed my first cervical fusion stated the other disc in my neck look great.
I have not been able to work in over a year and had to close my manufacturing business where we manufactured PEEK hip and knee sizing trial for Medtronic’s along with some instrumentaton. I was involved in manufacturing the sureshot drill sleeve for Smith & Nephew. I need to get back to work but I don’t want to risk my health and doing further damage to my spine by doing too much too soon.
Any information you could offer would be greatly appreciated and I want to thank you for having this forum as it is a great source if information. I can’t think of too many busy surgeons that would offer a platform such as yours.
With warmest regards, I am;
Sincerely,
Michael W. Couch
One other bit of info is I take 400mg of gabapentin x 3 daily for the left leg pain. I have been on his medication about a year before surgery and honestly I am not seeing much benefit from medication. Would it be advisable to switch to Lyrica. I know the costs is substantially higher but at this point I will pay the cost as I am not sleeping but for an hour or so a night and this goes on for days and then finally my body just left exhaust and I will sleep for over 24 hours at a time. I know this is not healthy and I have cut a considerable amount of weight due to lack of appetite from pain related issues.
Also, I am a 50 year old male soon to be 51 if that is of any use
Michael
I do not understand why your surgeon performed a microdiscectomy when originally he thought you needed a fusion and wanted to perform an ALIF (anterior lumbar interbody fusion). Instead of performing a posterior decompression and fusion when the insurance company denied the original request, he performed a simple decompression. Why your incision was 5 inches instead of one inch and why staples instead of suture were used is a question I can’t answer.
Removing more than 50% of the facet can lead to instability and/or fracture of the remaining facet. The fact that your pain is more intense and changed (“Since my surgery my leg pain is worse and different. The pain is sharper than before surgery and now extends below my knee. My leg pain is in my left groin, left knee and shin and calf area”) leads me to believe that you might very well have developed collapse of this foramen. You will need a new MRI and a CT scan. Depending upon the results (hopefully just a seroma present and not collapse), you might need something as simple as an aspiration and injection or something as significant as a redo decompression and TLIF fusion (see website for TLIF).
“Are my expectations unrealistic in thinking my leg pain would be gone or better and not yet be 1 month post-op”? Your leg pain should be improved after surgery.
“With my chief complaint being low back pain will the micro-D do anything to help with my low back pain which is my biggest generator of pain or will this procedure only address the pain in my left leg? Because my low back pain is worse and I realize some of this is due to the traum of surgery”. Generally, a microdiscectomy has a 50% chance of alleviating back pain in certain patients. A fusion is the preferred surgery for proven discogenic back pain.
“What type of post-op imaging would you reccomend to confirm how much disc material and how much of the facet was removed. Would it be out of order to ask for a copy of the surgical notes for myself to have or should that be best for a different surgeon to request the surgical notes? I have a file several inches thick with reports of all MRI’s, CAT scans, discogram (torture) and basically anything to do with my low back”. At my hospital, we mail out the operative report to every patient and you have a right to own and view that report. The correct imaging for you would be an MRI with gadolinium and a CT scan.
“)How soon after L4/5 micro-d would you suggest starting physical therapy. I was told prior to my surgery the nursing staff would get me up and do some walking same day of surgery. That did not happen but upon being released I started walking short distances and my left leg has gone out on my several times all but one was I able to catch my self on furniture and the other time I fell to the floor. After reporting this to my surgeons PA he prescribed a walker that I use. What I mean by going out is while walking it step using my left leg and it feels as if there is nothing there and my leg buckles and I fall”. This is serious. If your leg buckles now and did not before, you either have pain inhibition (a shooting severe pain that causes your leg to buckle) or actual motor weakness. I would assume that someone (hopefully attending or maybe chief resident) did a thorough examination to look for this.
It is time to get a second opinion for an experienced and meticulous spine surgeon.
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.Thank you so much for your reply.
I believe the leg collapse is due to motor weaknesses. I had a little motor weakness in my left leg prior to surgery but never fell. Hard to explain but sometimes while standing my left leg feels heavy and then there were the times it “went out”.
Post op the surgeon told my wife I had quite a bit of scar tissue from all the blocks I’ve had over the last 23 years. According to my records I’ve had 47 blocks at L4/5, epidural, facet injections, nerves burned….. goes on and on. Only 2 blocks in my cervical spine to get me through until I could get on the surgical calendar. For the most part I have no doubt issues from my cervical fusion.
I was shocked to find out I had staples. My incision was just to the left of my spine and having staples in my back made it very painful to sit back or lay down on my back.
About 1 week post-op my incision site was raised up approx a 1/2″. My wife actually measured it. When I brought to the Dr’s attention at first post-op he was VERY QUICK to state there was no leak. I’m not saying there was because I did not have spinal headaches which I have experienced 3 time after blocks all by different Dr’s. But something caused the surgical site to rise up like that and it’s still that way today.
The last interventional pain Dr I had been seeing thought I should go ahead with surgery as the blocks were no longer working for more than a couple of days to a couple of weeks. He had “no dog in the hunt” since he is in a solo practice and does not do surgical procedures.
I’m shocked and very dissatisfied with the end result.
I live in Alabama do you know a competent Neurosurgeon that will give me a fair and impartial work up? I live exactly half way between Birmingham, Al and Atlanta, Ga.
Honestly I feel I was set up to have a second surgery since the surgeon stated “sometimes you have to play games with the insurance companies to get what you really need”. Also stated the BC/BS currently considers an anterior approach to be experimental.
Thank you again for your time!!!
Sincerely,
I am dazed and confused in Alabama.
Michael Couch
First-do not focus on finding another neurosurgeon as you will probably find great care with a spine surgeon. Spine surgeons are orthopedists who in addition to their orthopedic residency complete a spine fellowship. You will find their care to be very good. I am a spine surgeon.
Second, if your surgeon did not perform a thorough physical examination after the surgery when your symptoms became worse and especially since you have greater potential weakness, you need to find another surgeon or confront your neurosurgeon as to how your current status occurred. A good physical examination will identify which muscles are weakened and shed light on your current neurological condition.
I know that BC/BS does not consider an anterior surgery to be experimental although you will find that neurosurgeons prefer an anterior approach and spine surgeons prefer a posterior approach in general.
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.Per our last conversation you suggested I get the operative report from my Micro-D surgery on June 7, 2017. The notes are as follows:
Physician Quality Reporting Incentives Indicators:
ASA Score: ASA 3 – Patient with moderate systemic disease with functional limitations. Prepping antibiotics discussed. 1 gram IV Ancef given at 0935 hours and ordered for an automatic stop after 24 hours. Skin incision was made at 0957 hours. Skin closure accomplished at 1051 hours. TED hose and SCD hose were placed on the patient’s legs prior to intubation.Operative findings:
Patient had a combination of a protruding disc, this was a subcapsular herniation impinging the traversing L5 nerve root and combined with large facet compromising the exiting L4 nerve root. Essentially after facetectomy was performed on the left side. The herniated disc material was impacting the L5 nerve root as it was traversing and far laterally was putting pressure on the exiting L4 nerve root. The facet was drilled away with a high speed drill underlying disc was then incised and removed. Murphy ball hook passed freely with both L5 and L4 nerve roots at the end of the procedure. Micro dissection techniques were utilized using operating microscope. Patient had neuro monitoring and there was diminished sensory over the L5 nerve root at the beginning of the case and this did not seem to improve with surgery, weasel same as baseline.Procedure in detail:
Patient was taken to the operating room, satisfactory general endotracheal anesthesia obtained. Patient was carefully turned and positioned prone on an operating table. Back was shaved and prepped in usual fashion with Betadine solution. Sterile towels, drapes, and Steri-Drape created a sterile field. Time out between surgeon, anesthesia and circulating nurse was then performed to verify patient, levels and laterality of proposed surgery. Sharp incision was made two fingerbreadths from the midline on the side of the level of pathology.
Subperiosteal dissection to the level of the lamina and facets on the side of the patients pain. Midas Rex drill and Kerrison rongeurs were then used to perform a partial hemi-laminectomy on the affected side. Micro-Dissection techniques were utilized to expose the nerve roots. C-arm fluoroscopy was utilized to confirm level and location of the disc space. The nerve root was held medically with a nerve root retractor, the ruptured disc identified and removed with a variety of disc rongeurs and scraping instruments within the disc space. Murphy ball hook passed freely with the nerve root at the end of the procedure. Hemostasis was achieved using bipolar and thrombin. Copious quantities of bacitracin irrigation were utilized. Deep fascia was then approximated with 0 Vicryl, subcu with 2-0 Vicryl, skin with staples. Patient tolerated the surgery well, went to recovery room in satisfactory condition. Patient is not yet awake at the time of this dictation.I have a question about the following: Patient had neuro monitoring and there was diminished sensory over the L5 nerve root at the beginning of the case and this did not seem to improve with surgery, was same as baseline……. what exactly does this mean.
I asked the surgeon if he planned to perform any type of physical exam to help determine the cause of the new and extremely pain condition affecting my left buttock check, the back of my left thigh, back of my left calf and the numbness on the top of my left foot…. he stated there was no need for a physical exam as these symptoms were to be expected and “IF” they were going to go away it would take 6-12 months.
I inquired about why he didn’t consider a TLIF procedure and he again stated BC/BS would not pay for a fusion unless I had one, two and possibly even three failed back surgeries. I have discussed this with several other surgeons over the past few weeks and they all find this to be non-factual. Why would a person have endure multiple failed surgeries in order to get the surgery they truly need unless this is a ploy being used to enrich the surgeon. I find this to be extremely unethical and might even border on malpractice. I recorded my 2 follow ups after surgery where he stated BC/BS would not approve an anterior lumbar inner body fusion and then when he stated I would require up to 3 failed back surgeries before insurance would appprove fusion.
Initially he refused to order post surgical imaging but after a heated exchange he agreed to order code V67.4/Z09 72158 MRI LUMBAR SPINE W/O & W/DYE and code V67.4/Z09. 72114 X-RAY EXAM OF LOWER SPINE – COMPLETE ap/lat flex ext obliques.
Also based on your advise I have found a Orthopedic Spine Specialist who is actually a revision specialist that I will try to schedule an appointment with once I have my MRI and X-RAYS.
If you would advise about the diminished sensory over the L5 nerve root I would greatly appreciate it. I don’t understand what this means and has me concerned. My surgeon did not have time to go over this report with me.
Also, I will not be returning to the Neurosurgeon that performed my Micro-D. I only went to today’s follow up because it was already scheduled and I wanted to pick up a copy of my operative report. I still have severe motor weakness in my left leg and have to use a walked due to my leg “going out” on a regular basis and I don’t want to fall and further complicate my injuries.
Thank you for your time and the dedication it takes to maintain this forum. You are truly an exceptional person and Dr to put the time in to answer all the questions you get.
Warmest regards and still confused in Alabama, I am;
Sincerely,
Michael
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