[Jtal19305]

#20841

Hello

I had an MRI in June of 2015 which revealed a large disc bulge at T12 / L1 and severe stenosis at L2/L3. I was having leg pain (left outer thigh tingling and numbness) and leg weakness prior to the MRI, along with fasciculations in my calves that started in May of 2015. Most of my leg pain was on the left leg, but both legs started to get very weak toward the end of June. I was also beginning to feel some slight pain in my genital area in June of 2015. I also had minor scoliosis (curving to the left side) as a teenager; the curve was not more than 14%. I am a healthy weight, active 48 year old male.

My doctor stated that I need surgery to decompress those areas. So on June 29, 2015, he performed a posterior lateral laminectomy disectomy fusion with instrumentation at T12/L1 and a hemi (left) laminectomy at L2/L3 The surgery in his opinion was a success, however, I awoke from surgery with a burning pain in the bottom of my left foot. The burning pain was very intense and has diminished a little but is still with me to this day (Nov., 24, 2015). I also started to have nerve pain in my left calve (and at times right calve) and still have it it to this day. So, after surgery, I developed new nerve pains in my left foot and calves, and the pain in my outer left thigh is still there. I still have the fasiculations in my calves and feet a slight pain sensation at times in my genitals. I did not have back pain prior to surgery and I do not have back pain now.

I have had two MRIs after surgery and a CAT scan afterwards as well. The doctor says he does not see any compression and to give it more time to heal. However, I have my doubts since I still have pain and it has been almost five months since the surgery was done. Another orthopedic surgeon I saw recommended I get a CT myelogram but my doctor did not recommend that unless another surgery is planned. So I am a bit stuck on what to do next. The pain has been very hard on me. I can walk but my strength is limited and my daily activities and social life are limited. I am also still off of work due to this. I am doing physical therapy to strengthen my muscles.

After my own research I realize how rare this operation was. And there is not enough information out there on line for me to know what I should expect. So I am reaching out to you for any advice, direction on what is going on with me, and what I should do next.

Thank You!
JERRY

[Donald Corenman, MD, DC]

#20850

This area of spinal canal that hosted the herniation contains the spine cord at its end (the conus medularis). Surgery at this level (as well as the disc herniation itself) can cause some cord irritation or even damage.

Burning symptoms with weakness generally can indicate nerve or cord injury. If strength is limited and symptoms continue, I think a full work-up is in order. I would assume the two MRIs and the CT scan should be sufficient to image the region but if there is significant artifact from the metal instrumentation, a CT myelogram could be helpful. Were there any significant findings on these studies?

What does the physical examination demonstrate? What are the sensory and motor portions of the exam specifically? Is bowel and bladder functioning well? Hopefully you were given your clinical notes and have a record of the full physical examination. I just put a new section on the website regarding how to do your own motor examination at home. Find it under lumbar spine diagnostics.

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.

[Jtal19305]

#20862

Hello Dr Corenman

All of my physical tests and reflex tests were normal. My left ankle reflex was faint but still there. After further review with another independent expert on spine MRI, it appears that the decompression of L2/3 (left side hemi laminectomy) was not complete. There was evidence of something (e.g. scare tissue, bone spur, ligament, etc) pressing on a nerve root on the left lateral recess area. The surgical report stated that the part of the facet joint was removed on the left side but the MRI did not show that. So the pain that I still have on my left anterior thigh may be due to the inadequate decompression. He suggested a selective nerve root block at L2/3 to see if the clears up the thigh pain. If it does, then a steriod injection. If that doe not work, then finding a surgeon to decompress that area without fusion.

What are your thoughts about revision surgery? In a case such as I described where there is a definite compression, can revision surgery over the same area resolve the issue? I understand the concept of scar tissue but if there is something compressing a nerve, something should be done to remove it while minimizing scar tissue.

The expert thought a spine fusion at t12/l1 may have been too drastic for someone my age (48). His suggestion was a laminectomy or just a disectomy to remove the protrusion. I could only recall that my surgeon thought that area of my spine would be unstable due to some khyphosis. In any event, I cannot undo what as done. He felt that my conus was most likely irritated during surgery, and the foot, back of calf and genital pain which are the s1, 2, 3 nerve roots are in that area where surgery was done. Its a little strange that the pain is mainly on my left side but that is the side the interbody cage is placed in. The expert said it may take many more months for things to settle down and the pain to reduce. There were also good size bone spurs behind the canal at t12/l1 which were not removed during my surgery. The expert did not know why the surgeon did not address that. I could not tell him other than maybe he felt it was too risky to move the cord in that area to get around to the spurs. Again, the expert recommended a selective nerve root block bilateral at t12/L1 to see if that resolves any of the foot, calve, genital pain. In a good note, the expert felt the decompression of t12/l1 did resolve the bilateral leg weakness, and there was a little more room created by the laminectomy disectomy and fusion at t/12/l1.

So I am a bit upset at myself, and my surgeon for getting into this position. It appears some of my surgery (t12/l1) may have been overkill, and the other part was not done sufficiently. So, I am left (5 months and going after surgery) with pain in my left anterior thigh, left back of calve, bottom of left foot and some pain in genital area as well as fasiculations in my calves. I am looking at the prospect of revision surgery to clean up and properly decompress those areas. Unfortunately, I was not as educated and informed prior to my surgery as I am now. I realize how important knowing what is going on, and working with the right surgeon to do all the necessary pre workups to come up with the best surgical plan. Also, having a surgeon that is good and thorough at what they do is critical.

So, I would appreciate any advice on how to proceed from here. I can chose from three areas to have revision surgery – the Philadelphia area (where I work), South Florida (Where I had my original surgery, and have a condo) and Detroit Michigan (where I grew up and have family). I need to select the best practice, and was told to look at a teaching hospital. Any suggestions or advice on proceeding with revision surgery, and the what type of outcome I can expect if I have the best team/practices in place.

I know this is a long reply, but please understand that I am desperate to fix my situation. I never expected to be in this situation. I trusted my doctor, and realize I was not treated with the best care possible. All along the way after my surgery, my doctor has ignored my calls for help only telling me to give it more time. He did not look at the post MRI images in the detail necessary to see the issues. He did not suggest any diagnostics like nerve root blocks, emg/ncs, etc. I have been through your site, and information. I realize there are many levels of surgeons out there and to be very careful on selecting someone to operate on you.

Any help/guidance would be greatly appreciated.

Thanks
JERRY

[Donald Corenman, MD, DC]

#20867

You have a number of points and I will try and comment on each one.

First, the fusion at T12-L1 along with the decompression. Any decompression at this level (or any cord level in the thoracic spine) needs a fusion in my opinion. The problem is with abnormal motion and stress at this level which is what initially caused the disc spur and/or herniation. You do not want re-operation here as scar, recurrent herniation or recurrent bone spur can occur. A redo operation here is fraught with problems so a fusion is required.

I generally do not do TLIFs at a cord level because of the retraction necessary. Your comment, “Its a little strange that the pain is mainly on my left side but that is the side the interbody cage is placed in”, fits with a retraction irritaion to the cord at this level.

Your comment, “it appears that the decompression of L2/3 (left side hemi laminectomy) was not complete. There was evidence of something (e.g. scare tissue, bone spur, ligament, etc) pressing on a nerve root on the left lateral recess area” is important. WHat tissue causing compression that remains is important. If it is scar and there is no lateral recess or foraminal stenosis, this might make a revision surgery less effective. Hopefully, you have had standing X-rays as well and MRI and/or CT scan to determine if lumbar instability or lumbar foraminal collapse is present (see website for descriptions of these disorders).

I am a big fan of SNRBs for diagnosis and endorse this plan. You do have to remember that these blocks identify the structure (root or cord) involved but do not help to differentiate between causation due to compression and internal nerve injury. In either case, if the structure is anesthetized, there should be temporary relief.

I cannot endorse specific individuals or locations at this time but eventually will have a system to help patients make decisions. That is at least a year away.

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.

[Jtal19305]

#20870

The surgical report indicated that the surgical approach to t12 l1 was from a posterior latereal approach. I imagine it was far lateral as my incision in my back was 4-5 inches down the center of my spine. L2/L3 hemi laminectomy was about an inch incision slightly off to the left side of the center. For t12 l1 the surgical report indicated he did not touch the dura sleeve or spinal cord and no retraction was necessary to inset the cage. I also asked him this in person and he stated the same thing. Neuro monitoring was performed during surgery and nothing unusual was reported. The surgeon was entertaining an anterior approach but felt that approach had greater chance for issues

I’m not a surgeon so I would not know if the fusion with interbody 10 mm peek cage can be inserted without manipulation of the cord (thecal sac). Can you shed light on this? If it is likely he had to manipulate the cord would that explain waking up with the burning pain in the sole of my left foot? And does this get better or heal in time? I am dealing with multiple pain patterns that I’m trying to diagnose and find a solution. It’s hard to get feedback from my doctor as he is probably protecting himself and is biased. I want to believe him but why the protracted pain in my feet, back of calves and genital area. I also noticed from the ct scan that he did not remove any of the bone spurs behind the cord that are still encroaching the canal area. Although I’m decompressed from the posterior side, I don’t know if the Spurs are causing issues. I had one doctor indicate it would be too risky to get them from the posterior side as retraction would be necessary and they are so close to the cord. Also he stated if I have been living with them for so long, the may not be the issue.

I feel a little better with your assessment that fusion is preferred after that procedure I had at t12 l1 as the facet joint is removed and the area could become unstable. I also recall my doctor indicating I was slightly over kyphotic at that level and fusion would prevent any collapse. Other doctors indicated fusion should of been avoided and just do a plain laminectony or disectomy. I have also wondered why he didn’t approach from the side just to remove the bone spurs. I have good cat scan images (saggital and axial) of these spurs. Since the vertebrae are now fused, would the spurs dissolve on their own? I imagine the spurs were forming as the body’s means of self correcting an instability that was forming at my thoracolumbar spine. I did have slight curvature of the spine (scoliosis) toward the left (recall curve being not more than 15 degrees). Although scoliosis can cause rotation as well of the spine. I suppose my body found an equilibrium point for a while but eventually due to all these factors and a bad back due to genes things went south quickly.

So is it best to leave the hardware in place? I’m told by my physicians assistant that the fused vertabrae will be very strong. I understand adjacent segment disorder and I hope I can avoid it by keep healthy body weight and strong core. I’m only 48. Of course, this would be easier and so would my life if the nerve pain and foot burning fully resolves. So I take it the best thing to do is leave t12 l1 alone.

As for L23, I have not had post surgery standing x rays. Are these the flex extend 3 foot x rays? I have an appointment with my doctor who did the surgery so I will ask for these. I must admit I not feeling confident he has a good diagnostic plan for me. This is why I’m seeking outside opinions and help form other specialists. I have had post surgical mri and cat scan but not standing up if that is what you mean. I would imagine I am due for another Mri and/or cat scan. Is one better than the other ? Would a ct myelogram be better although I know doctors do not like to order these unless planning for surgery?

The pain in my left outer thigh comes and go; sometimes it is very minor while other times it is very numb and sharp. If it’s scar tissue adhering wouldn’t the pain be more constant? This is the area where I think I can find benefit but I must follow the appropriate algorithm to diagnose the issue. If it is determined to be punched by something other than scar tissue, is the approach directly over the existing incision or can it be a transforminal endoscopic approach? Or something else as to minimize more scar tissue and a procedure that can decompress that side ares without requiring fusion? I had one orthopedic surgeon suggest an alif st L23; I was skeptical.

I would love to visit your clinic but you are far away from me. I am looking at university of Pennsylvania spine doctors as I will be in that area soon. I am in south Florida now but cannot find someone with the attention to detail and knowledge such as yourself.

Does your clinic offer a service where mri / cat scans / reports can be reviewed with a telephone or Skype consult? I understand it’s best to be fully examined in person with new imaging but wanted to check. I appreciate your time and attention into my case. I’m ready to do anything to find solutions to my issues and get pain free. I believe if I have the right medical professionals working for me I would have a plan to solve this. I will keep at it until I have fully resolved this. I deserve to be better.

Thanks
Jerry

[Donald Corenman, MD, DC]

#20875

Sorry but at this time, I do not do long distance consults for the general public. I probably will but that is a year away.

Getting a 10mm cage into the disc space at T12-L1 would be difficult without some retraction in my hands but maybe this surgeon has a better technique than I can deliver. The burning would fit with some cord irritation at this level as it does not fit with a lateral type technique at L2-3. L2-3 would affect the L3 nerve root which radiates to the anterior thigh and does not go into the foot.

I think fusion is important with a decompression at a cord level as noted before. If the canal is decompressed by a laminectomy and the disc herniation was also removed with an included fusion, the remaining bone spurs probably won’t cause you any grief. This is as long as the canal has been reasonably decompressed.

You don’t need a stand-up MRI as those have generally diminished signal to noise ratio and are poorly diagnostic. You also should not need a long film (called a full spine film). You simply need lumbar X-rays (that include up to T10) standing with flexion and extension views to determine if there is instability or lumbar foraminal collapse present at L2-3.

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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