Computer_JockeyMemberDecember 13, 2011 at 11:08 amPost count: 2
After years of sitting for a living, thinking all backaches were muscular in origin, my L4/5 disc ended up with a large herniation with extrusion and mass effect on L5 nerve root. This happened about 8 weeks ago. Initial Sicatic symptoms of pain and weakness have been reduced about 80-90% after 2 epidural injections. Worst symptom seems to be pulling sensation around ankle. On stringent course of PT for strength and posture correction. Walking several miles per day plus doing other strengthening exercises. However, there is still no ability for flexion, thus shoe tying, etc. is out of the question. I’m wondering what your experience has been with conservative management of this type of situation. Is this still fairly early in the resorption period, is full recovery possible without microdiscectomy? On the one hand I’m encouraged that I feel as good as I do in a neutral position, but on the other hand it seems like it may be quite some time (months) before fully resolved. Is this a wise move to continue conservative care given the results thus far?
Thank you in advance for your consideration and advice.Donald Corenman, MD, DCModeratorDecember 13, 2011 at 1:46 pmPost count: 8436
Unfortunately, most “muscular back aches” are really from degeneration of spinal disc, nerve or facet. A disc herniation compressing the nerve root will cause mainly buttocks and leg pain but there are variants that can cause only lower back pain.
My recommendations for non-surgical care of disc herniations are that there is no motor weakness (except the extensor hallicus longus- big toe lifter) present and the pain can be controlled and improves on a timely basis. There is some data that indicates surgery performed after six months has poorer results than if done before the six month period.
That being said, what I tell my patients is that if they go through a good rehab program, epidurals and proper medications and still after 6-8 weeks are dissatisfied with their pain or progress, I would consider surgery. It is really a patient decision regarding whether to do surgery or continue down the course they are on.
Of course, if there is motor weakness, I recommend surgery sooner than later.
Dr. CorenmanComputer_JockeyMemberDecember 14, 2011 at 3:26 amPost count: 2
Thank you very much for your prompt reply. I have no motor weakness after recovering quickly from a severe sciatic episode 5 weeks ago (induced toileting and led to treatment), and when sciatica symptoms aren’t active, there is no issue with big toe raise. I have been under active care for 4 of the 8 weeks since the rupture. The first four I either ignored symptoms or exacerbated them with my “home remedies” such as heating pads. Thus, I may not have given the conservative route it’s full benefit at this time. Your response seems to echo the results of the SPORT trial. I will certainly assess the situation on an ongoing basis with my Orthopedist. My thoughts are to request a second MRI at the three month mark, note any reduction in herniation mass, and make the decision for surgery at that time. Both Neurology and Orthopedic specialists have been very hesitant to recommend surgery at this point. I see that there is a lot of data on the subject that supports both routes. What percentage of microdiscectomy procedures run into the “straw that broke the camels back” situation where the sciatic nerve is damaged beyond repair leading to paralysis, etc? Is this really a procedure to fear? Thanks again for your advice.Donald Corenman, MD, DCModeratorDecember 14, 2011 at 7:47 amPost count: 8436
The MRI at three months will not be necessary unless symptoms change for the worse or surgery is considered. If surgery is considered, a new MRI is warranted. I saw a patient just today who had a herniation 6 months ago and has continued leg pain. A new MRI revealed that the herniation is gone. Continuing leg pain in this circumstance is most likely chronic radiculopathy (see website).
There is really no way to know if you might have permanent nerve damage unless you have surgery. The chance of chronic radiculopathy has to be balanced by the risks of surgery itself.
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