[deritis]

#9818

Hi Dr.,
I had an L5/S1 microdiscectomy a little more than two weeks ago. I am now entering my 3rd week of recovery. Pre-op, my symptoms were moderate to severe pain. Most notably, there would be a crippling explosion of pain in my right rear upper leg and buttock whenever I rose from a seated position that was easily a 10 out of 10. A round of epidurals didn’t help, so I opted for surgery.

My question is: I still have sciatic pain, but mostly in my right buttocks that would rate about a level 3 at max. And only in certain positions. I also have an occasional mild ache in my left Buttock. Why is this? I worry about reherniating. I have been walking and doing the elliptical, per surgeon’s direction, pretty much daily. I can sit and stand mostly fine, though every now and then I feel a twinge.

The lingering pain also seems to be more pronounced in the morning. I worry that any jolt or slip, however minor, could cause reherniation as well. Can you provide some guidance and context? thank you.
-Eric

[Donald Corenman, MD, DC]

#9819

You have had reasonable relief at this early stage from your surgery. Prior to surgery, you had significant pain especially with rising up from a sitting position. This was probably due to the nerve “getting caught” in the transition. The nerve actually moves like a cable over a pulley when you rise and the herniation probably trapped the nerve when rising.

The pain has receded to about a three which is good. Remember that the surgeon removes the herniation but mother nature has to heal the nerve. This takes time and sometimes, the surgeon has to help the nerve along with steroids (either oral or injectable). It may take three to six months for the nerve to resolve from healing (longer if there is motor weakness previously present).

The nerve may always be somewhat more sensitive. This is not uncommon.

I cannot tell you why you have some opposite sided pain. I have seen this and it may be due to pain crossover in the cord level (the pain tracts cross over each other at about the T10 level) but that is just theory.

The nerve will swell during the night and a more swollen nerve in the morning is more symptomatic. Standing and walking should relieve the swelling after about 20 minutes.

Reherniation is more common during the first six weeks after surgery so your biomechanics have to be “better behaved”. Hopefully, your therapist has discussed with you how to bend lift and twist to keep you out of harms way.

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.

[deritis]

#9846

Thank you doctor for a thorough answer. It makes me feel far less anxious about my situation. I’m three weeks from surgery today and still feel the occasional twinge and aches where the pain was before. But again, it’s much more tolerable. I am also eager to get back to the point where I can teach spin classes again. I’ve been a spin instructor for a few years and very much enjoy it. Right now, I walk a few miles a day and do 30 mins or so on the elliptical. And a lot of stretching. I generally feel very very good afterward.

In certain positions — such as when I lie down on my back, knees up, and cross my right leg over my left — I will feel a pretty sharp twinge in my right rear. Also if I am laying in the same position with legs straight and shift my legs or hips slightly, the same pain often occurs, though it tends to recede as I stretch. I take it from what you say that I have not reherniated. Only that the nerve is still sensitive and firing off when I tug at it, or otherwise stress is.

Re: Physical therapy, my surgeon basically told me it’s not really necessary for me and encouraged me to do what I do at the gym and gently ramp up over time. But I will ask to see a PT as I suspect part of the reason I herniated in the first place was due to bad form during certain exercises. Thank you again.

[Donald Corenman, MD, DC]

#9849

Good spine therapists will teach you how to bend, lift and twist to break your old bad habits and prevent further stress to the disc. These therapists should also work to teach you about engaging core strength and the exercises necessary to maintain this strength.

“Nerve flossing” is also important. As I said earlier, the nerve acts like a cable over a pulley. Surgery always forms some scar tissue. You will want to move the nerve while the scar is “setting up” to prevent adhesions to the nerve. This is “nerve flossing” and is important to do in the first six weeks.

Nerve flossing is simply the same action as the stretch of the hamstring muscle. This movement also stretches the nerve root itself. The key is to gently stretch the root without increasing inflammation which will cause greater nerve pain. This is the art of medicine.

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.

[deritis]

#9866

I’ve asked my surgeon to refer me to a therapist to make sure I am moving correctly. Which he was happy to do. He seemed to feel early on that therapy wasn’t necessary for me. I was a regular exercise enthusiast pre-op and he seemed to feel that going back to the gym would be the best route. He was very clear about me not lifting any weights and no running. But he said cardio such as walking, cycling or elliptical would be fine, even in the first week after surgery if I felt up to it. He also said recurrence of pre-op symptoms is common for a few months or so. Interestingly he said the evidence that normal bending or twisting can cause reherniation is pretty slim. Lifting weight or high impact moves like running are more clearly linked. He said follow what my body tells me. If it hurts don’t do it. Or back off. He also said that working out is fine, but to be more conservative about it for a while.

I am now at week four. Things were much better following this guidance from him until yesterday morning when the pain became more severe. Still not to the levels of pre-op pain. But more concerning. I thought (hoped) that I had pushed a too hard stretching and doing cardio two days prior. So I have rested more and it seems to be better, but still irritated. I hope this is an indication of over stressing the nerve rather than a reherniation. I’d like to think reherniation would be pretty obvious. Can you shed any light on what to look for in terms of symptoms in each case? Thank you Doctor.

[Donald Corenman, MD, DC]

#9908

A reherniation has similar symptoms to an aggravation of the nerve. With an aggravation, the symptoms are generally not as intense and recede when the aggravating activity is discontinued. This still might take two to three days. With a reherniation, the symptoms are more intense and will not “calm down” over a 2-3 day period.

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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