nyquistParticipantMarch 23, 2022 at 12:40 pmPost count: 4
Hi Dr. Corenman,
I would love your opinion on my thrice-herniated L5-S1, specifically if you would ever recommend a 3rd discectomy or insist on something else (fusion or artificial disc).
I had a discectomy/laminectomy in Feb 2021 and I am pretty sure it immediately reherniated as the pain was slightly improved but still bad right away. My surgeon refused a second MRI until 6 months post-op, which did show a significant new herniation.
I left for a new practice who performed a minimally invasive discectomy in February this year, which was light years easier to recover from. I had 3 weeks of improving pain to the point where it was just about gone before it suddenly came back (butt and leg pain) at the 3 week mark.
I had a new MRI last week that showed a new, albeit smaller for now, herniation at L5-S1. The report also noted a moderate to severe left foraminal narrowing. The surgeon wants to do another minimally invasive discectomy to cleanup the new herniation. I wanted to see if you ever recommend a 3rd discectomy or if you would move to a more invasive procedure at this point.
Thank you very much for your insights. I put the important parts of the report below, the rest of the spine is “there is no evidence of focal disc protrusion, spinal canal stenosis, or foraminal stenosis.”
Interval postsurgical changes from right hemilaminotomy at L5-S1 with
grossly unchanged right subarticular disc protrusion and grossly unchanged
mass effect on traversing right S1 nerve roots. Unchanged foraminal
narrowing at L5-S1. Findings could represent recurrent disc protrusion or
granulation tissue. Contrast enhanced examination could be obtained for
further evaluation if clinically indicated.
At L5-S1, there are postsurgical changes. Again noted is a right
subarticular disc protrusion with mass effect on traversing right S1 nerve
roots. There is mild right and moderate to severe left foraminal
narrowing, grossly unchanged.
The conus medullaris is normal in position and appearance. There is no
evidence of epidural mass, fluid collection, or hematoma. The
paravertebral soft tissues are unremarkable.Donald Corenman, MD, DCModeratorMarch 23, 2022 at 2:39 pmPost count: 8468
Generally, it is recommended to do a fusion if the level has already had 3 herniations (HNP). The reason is scar generation, 4th recurrent HNP and the “battered root” syndrome.
These roots don’t like to be manipulated too many times as manipulation can cause root damage even without recurrent HNPs so the fewer surgeries to free the root, the better. We have figured that 3 decompressions should be the maximum number to prevent battered root.
A disc that has already spit 3 herniations out can easily herniate again. For the first three HNPs, it is noted that recurrence rate is about 10-20%. However, after the first three, the reherniation rate goes up possibly to 50%
Finally, every time the root is decompressed, there is scar that forms. This scar only multiplies with each subsequent surgery. Again, it seems like three is the magic number here too.
Then finally add severe left foraminal stenosis due to the loss of disc height and degeneration bone spurs that occur. This will not get better with a redo surgery but could get worse and become symptomatic. I would advise a decompression and fusion of this level.
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