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** I’m submitting this again, because I didn’t receive any confirmation that it was received. Thank you.
Hello Dr. Corenman,
Thank you for addressing my questions. I’m currently having recurring symptoms of left leg sciatica which began 8 wks post-op MI microdiscectomy.I am a 59yo female and retired RN with newly diagnosed advanced osteopenia of my lumbar spine. I have a 20 yr history of manageable episodic left low back pain. I am otherwise fairly healthy (no smoking/drinking) and usually active.
In July 2019 I had a left low back pain episode and began having left leg sciatica symptoms, as well. 8 months later; after multiple conservative treatments, debilitating increasing left leg pain/neurological symptoms, an MRI & CT scan, an epidural steroid injection that only made things worse, and getting 2 surgical opinions (1-Ortho, 1-Neuro), I had surgery in March 2020.
My MRI (1/9/20) revealed a “Large broad-based left paracentral disc protrusion at L5-S1 with moderate to severe narrowing of the left side of the spinal canal contacting and displacing the descending S1 nerve root.” Also of note: “Moderate loss of height” with “chronic degenerative endplate irregularity and signal change present at L5-S1.” L4-L5 has a disc bulge without loss of height, and elsewhere all good height & alignment.
The Ortho did x-rays (4 views of the L-spine on 1/23/20) and reported “No obvious spondylolisthesis is noted.”, but saw on reviewing the MRI that the left L5-S1 facet joint looked dysplastic.
The follow-up CT scan (2/4/20) agreed with the MRI findings regarding herniation but also revealed a “Left L5-S1 spondylolysis.” (later explained by the Neuro as an elongated pars interarticularis) and “bony gap/defect right lamina of S1 resulting in an independent S1 posterior spinous process and left lamina, not contiguous with the rest of the S1 lamina.” (the Neuro agreed this was likely an asymptomatic spina bifida occulta I was born with).
My post-op course was mostly uneventful. I had immediate relief from all left low back pain/sciatica/neuro symptoms on day one. I was careful throughout my early recovery. No BLT, gradually increasing my daily walks & light household chores, some light stretching, and resting/icing if I was sore.
I had a follow-up with the PA at 4 wks. My wound was healed. He said I was past the point of reherniation, and he cleared me to begin some PT on my own at home. I waited until 6 wks post-op then added daily stretching/nerve flossing/strengthening exercises along with walking 1-2miles every other day.
Everything was going well at 2 wks. Then I did some morning exercise and an afternoon 2 mile walk on a Friday. Saturday morning I woke up with a very familiar left butt ache & stabbing pain in my outer left thigh. I immediately did rest/ice/Motrin without relief. My pain is now extending into my left calf & foot (like pre-op), and I also have some mild left low back pain with numbness in both feet. (Mostly when elevated in bed) Again, like before, I’m unable to sit/stand in one place for too long. Walking is also painful. Lying flat on my back with my knees elevated is the best position but not without some pain. I keep moving as much as possible. I can function on most levels short term, but it’s constantly gnawing at me. Fortunately, I don’t have the severe leg muscle spasms this time, so far. This week my neurosurgeon put me on a short course of steroids which gave only mild symptom relief. I have an appointment to see him soon and assume he will order a repeat MRI.
Does this sound like either a seroma or reherniation to you? If it’s a reherniation and my surgeon recommends a revision discectomy, how successful do you think it would be? I would like to avoid fusion surgery altogether but worry about increased spinal instability due to the removal of more disc and my left pars defect at L5-S1. If for any reason I need a fusion in my future, is it too risky for me with the advanced lumbar osteopenia and the S1 bony defect (SBO)? Have you treated many patients with these added conditions, and/or performed successful fusions on them?
If the MRI is unremarkable, what should I try next? What would you recommend if I were your patient? I know it would be best to have updated MRI results, but I’m anxious for advice and also want to be more prepared speaking with my surgeon. Your opinion and advice is much appreciated! Thank you in advance.
Update (5/18/20)-My neurosurgeon has ordered an MRI w/o contrast for Wed. I’ll see him for follow-up a week later.
Your pars defect at left L5-S1 is possibly related to a spina bifida occulta (SBO) but there is generally an intact pars with an SBO. It appears if I read this correctly that you have a floating left facet (not connected). You note; “The follow-up CT scan (2/4/20) agreed with the MRI findings regarding herniation but also revealed a “Left L5-S1 spondylolysis.” (later explained by the Neuro as an elongated pars interarticularis) and “bony gap/defect right lamina of S1 resulting in an independent S1 posterior spinous process and left lamina, not contiguous with the rest of the S1 lamina.”
The microdisectomy was most likely successful as you experienced leg pain relief. I am worried about the stability of that side if your facet is not supporting the left. This could lead to foraminal collapse or lateral recess stenosis recreating left buttocks and leg pain. You do need an updated MRI to rule out seroma or recurrent HNP but even standing 4 view X-rays can be helpful to look for angular collapse (the AP) or slip (the lateral and flexion-lateral).
Let me know what the new MRI notes.
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.Hello, again, Dr. Corenman
Per your request, here are portions of the notes from my recent MRI (5/20/20). I copied what I believe are the most important.
“The lumbar lordosis is well maintained without subluxation, spondylolysis or spondylolisthesis. There is no scoliosis. The lumbar vertebral bodies demonstrate minimal spondylitic change in the lower lumbar spine with small Schmorl’s node along the inferior endplate of L5. Lumbar bone marrow signal is benign. No compression or other fracture identified. Marrow signal and morphology of the upper sacrum appear normal.”
“The L5-S1 level demonstrates postoperative changes of a left-sided laminectomy. There is a large recurrent left-sided L5-S1 disc herniation at this level directly compressing the left ventral aspect of the thecal sac with direct compression of the left S1 nerve root sleeve. There is normal appearance of the right-sided articular facets and right-sided ligamentum flavum. The left-sided spondylolysis at L5 identified on the CT is not identified on this MR.”
“The lumbar nerve roots of the cauda equina are normal. No epidural hematoma or collection. Benign postoperative signal in the posterior paraspinous soft tissues. Retroperitoneal soft tissues are normal.”
“Impression:
1. Sequela of left L5 laminectomy with large recurrent left paramedian disc herniation directly compressing the left S1 nerve.
2. Minimal degenerative changes at L3-4 and L4-5, stable in comparison to prior studies.”Since the MRI I have not had any discussion with my neurosurgeon. My appt. is on 5/26. Over the past few days I’ve been achieving some occasional relief of left low back/left leg symptoms by taking Motrin 400mg po q6h tid. Pain level 3-5 down to 1-2. However, I also need to take Colace tid with it (prone to constipation) and have a history of chronic superficial gastrtis so can’t live on these meds for long.
As you previously mentioned, do you think that getting standing 4 view
X-rays would still be beneficial? Any need for another CT?Are there other conservative treatments you would recommend I try before a revision microdisectomy?
In your experience, if revision surgery is necessary, what is the success rate?
What do you consider my best options to be at this point? Thank you, again, for any advice or guidance you can give.
Unfortunately, you have a large recurrent HNP where you had the prior decompression surgery left L5-S1. With your current symptoms, a redo microdiscectomy is typically recommended but with the CT report of a spondylolysis on that left side, I would be more inclined to consider a decompression and fusion. I am however somewhat confused that there was no identification of the pars fracture on this new MRI (“The left-sided spondylolysis at L5 identified on the CT is not identified on this MRI”). This could be due to a dysplastic (stretched pars) or that the fracture is so subtle as not to be identified. Make sure the prior CT scan is reviewed to confirm this pars defect or dysplasia as it makes a difference in the surgery you might need.
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.My understanding from the neuro is that the pars defect is actually an “elongated (stretched?) pars”. Prior to surgery he explained that this would actually make the laminectomy easier as it is thinner bone than normal. Does this make sense, and does it mean that he would have removed a portion of the dysplastic area during surgery? Could this add to it not being visible on the new MRI?
I will discuss my options for surgery with my neuro and take your advice regarding the CT. Thank you!
If the pars is dysplastic, then yes it is thinner bone but unfortunately, it is also more fragile. The less he removed, the better the chance the pars can remain intact (if it was intact-refuted per the CT scan).
Keep us informed.
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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