MASpineptParticipantSeptember 26, 2020 at 8:14 amPost count: 17
Hi Dr. Corenman,
I have found your website very helpful over the past couple of years, I’m hoping to get your opinion on my current concerns. I’m 33, normal BMI, 5’10”. 2 years ago i suffered a very bad disc her autism with extruded fragments that floated down my spinal canal- the herniation was at L5-S1 and I had motor weakness, loss of reflexes, almost complete foot drop. I had an urgent right sided hemilaminectomy by an orthopedic spine surgeon. Unfortunately my weakness and pain did not improve very much and after a 3 month wait and see/ further work up I had a neurosurgeon go back in to further decompress the area and extract the retained disc fragments which were missed on the first surgery. He said it was a mess in there, a lot of scar tissue, fluid, barely any disc left. My weakaness did improve but immediately following the second surgery I was left with a lot of back pain. The back pain steadily grew worse and worse, in Jan of 2020 I started having bilateral nerve issues in my legs which I was told was intermittent clarification from stenosis, I had a forminal collapse and spinal instability. Due to covid, my Emg was pushed about 3 months and our government shut down all
Elective procedures. Come June when I was finally able to complete the work up, we realized the situation with my right leg needed more acute intervention- Emg showed acute and chronic damage of L5 S1 and the neurologist agreed my unstable spine was also affecting the left nerve roots at times. A TLIF of L5-S1 was done on 8/5/20, I was told that day I also had a pars fracture. Following surgery my leg pain was actually worse, I was told
It could be irritation from BMP, had a corse Of steroids but that was not effective. Then I was told it will take 3-6 months to feel better due to the severity of my injury. I did have a post op MRI that showed fluid but nothing else (that was done 2 weeks post op). I do still get period of time when I can feel fluid and pressure in my spine, if I lay on my left side I can feel that fluid trickle into my hip/glut area-it’s very odd but it is happening less. I started physical therapy last week and since then all my symptoms have become worse and now I’m feeling new issues in my legs. The distribution of my nerve pain and weakness was always very specific, especially on the right side-it seemed consistently l5-S1-right gluts, going down the back of my leg, down the outside of my calf and then into my big toe. I have ankle weakness and eversion, dorsiflextion remains enough of an issue when I still cannot drive. The TA remains weak but I am able to compensate enough to walk around well. I do feel going up on my toes is improving. This week I began having pain in a new distribution-my anterior hip feels weak, down my anterior thigh, across and under me knee, and all along the interior side of my calf. I am having muscle twitching in some of these areas. This is all on the right leg but on the left leg I am getting some interior ankle/calf twitching now too, and also in my lower back/gluts. I have horrible back pain, worse than even prior to the fusion, I can’t lay on my sides for longer than a couple of hours without waking up in terrible pain.
I have a telehealth appointment set up with my neurosurgeon on Monday to discuss this. I still cannot sit for longer than 10 min without nerve pain, standing after a couple of minutes brings on bilateral nerve pain in what I think is L4-5. Intermittently, the bilateral heavy feeling when walking has returned.
Prior to discharge from the TLIF (8/8)I
had standing x rays performed and for the first time that I have seen the radiologist notes grade 1 retrolaliathisis L1-L4 (stepwise) and anterioroliathis of L4-L5 with right curvature. The hardware was in place.
My questions/concerns are; is this normal for 8 weeks post op? I understand fusions are difficult surgeries but I feel as though I’m getting worse than better at times. Is it possible that there is some post fusion misalignment? If previous MRIs noted facet arthritis at the above level, is it possible there is already an adjacent segment issue? I’m just having a hard time understanding why I am getting new symptoms. Thank you so much, your insight is most appreciated!Donald Corenman, MD, DCModeratorSeptember 26, 2020 at 1:21 pmPost count: 8455
“Prior to discharge from the TLIF (8/8) I had standing x rays performed and for the first time that I have seen the radiologist notes grade 1 retrolaliathisis L1-L4 (stepwise) and anterioroliathis of L4-L5 with right curvature. The hardware was in place….previous MRIs noted facet arthritis at the above level,…I have horrible back pain, worse than even prior to the fusion”.
All this (increased LBP after surgery, degenerative slip at L4-5) worries me that possibly only one of the levels was addressed and the slip level above could still be causing pain.
You note; “The distribution of my nerve pain and weakness was always very specific, especially on the right side-it seemed consistently l5-S1-right gluts, going down the back of my leg, down the outside of my calf and then into my big toe”. This sounds like an L5 or S1 nerve involvement which would fit with your previous disorder. However, you then note new pain: “began having pain in a new distribution-my anterior hip feels weak, down my anterior thigh, across and under me knee, and all along the interior side of my calf”. This sounds more like an L4 nerve involvement which could originate from L4-5.
Please cut and paste your new MRI report here. Hopefully you also had standing X-rays to go along with the MRI.
Dr. CorenmanMASpineptParticipantSeptember 29, 2020 at 6:37 amPost count: 17
The new symptoms are what concern me as well. I did have a phone conversation with the surgeon and shared with him how i am feeling;he thought the MRI at the higher lumbar levels looked great. He thinks these symptoms are related to the tlif and nerves being irritated. I guess this could be possible but im not completely convinced. He did share that i had terrible scar tissue around L5 and he really had to dig in to dissect it. I do respect his opinion. he is the chief nsurg at a top orthopedic hospital, but unfortunately i have had some poor outcomes from people being wrong in the past, so i may be a bit jaded.
As far as the back pain-its inconsistently better in the past couple of days. The surgical pain is better but i find that changing positions (especially from laying down-sitting-standing) is very painful in the lower back area. Also, i become very stiff when laying down and trying to change positions in bed is very painful and challenging-this is how things were pre surgery, as well. And depending on which side of by body i am laying on, my leg symptoms change-if that makes any sense
I do find with more activity i am getting more nerve pain both in L5-S1 (which i expect) but also in this new distribution. For example, last night after sitting/standing at my son’s hockey game my leg felt more tired and heavy to pick up from the floor when walking, my knee felt very weak and on the drive home i had nerve pain all the way down to the inside of my ankle. Below are the most recent reports for standing xrays and MRI. Thanks for your help!
PROCEDURE: MR 0109 MRI SPINE-LUMBAR Aug 21 2020 3:10PM
CLINICAL INDICATION: post op pain
CLINICAL INDICATION: post op pain
TECHNIQUE: MR imaging of the lumbar spine was performed without contrast
in multiple planes with multiple sequences according to department
COMPARISON: MRI from July 28, 2020
There are postsurgical changes related to anterior and posterior fusion
at L5-S1, with right-sided laminectomy and facetectomy changes.
Alignment and Curvature: Normal.
Conus and Cauda Equina: The conus terminates at the L1-L2 level and
demonstrates no signal abnormality. Cauda equina appears unremarkable.
Vertebral Body Heights: Normal.
Marrow Signal: There is persistent mild marrow edema at the L5-S1
endplates, likely reflecting Modic 1 changes..
Discs: Interbody spacer at L5-S1. Remaining discs are well preserved..
There is no significant canal or foraminal narrowing inferiorly through
L5-S1: There is postsurgical fluid along the surgical tract into the disc
space, which superiorly displaces the right L5 nerve root within the
foramen, for example series 3 image 11. There is persistent T1
hypointense material in the epidural space extending along the right S1
descending nerve root, likely reflecting scar tissue. The is no
significant bony narrowing of the foramina. The canal is patent.
There are postsurgical changes in the paraspinal soft tissues. There is
small amount of postsurgical fluid in the surgical bed.
The imaged upper sacrum and upper iliac bones appear unremarkable.
Miscellaneous Findings: None.
Lumbar postoperative changes at L5-S1 as described, with postoperative
fluid within the surgical bed and along the tract on the right side.
PROCEDURE: RAD 0137 XR LUMBAR SPINE 2-3 VIEWS Aug 7 2020 11:55AM
CLINICAL INDICATION: CHECK HARDWARE
EXAM: XR LUMBAR SPINE 2-3 VIEWS
COMPARISON: 02/17/2020. Correlation with MRI 7/28/2020 –
INDICATION: CHECK HARDWARE
FINDINGS: Upright AP and lateral views of the lumbar spine show
transitional anatomy at the thoracolumbar junction, with a lumbar-type
left transverse process and rudimentary right rib at what is considered
L1. There is a mild rightward curvature at L4-5. There is minor stepwise
grade 1 retrolisthesis from L1 to L4, and slight anterolisthesis of L4 on
L5. There are bilateral pedicle screws, posterior paraspinal rods, and an
interbody cage at L5-S1, and right-sided laminectomy defects.
Laminectomy and interbody fusion L5-S1 with fixation hardware in place.
NUMBER OF IMAGES: 2Donald Corenman, MD, DCModeratorSeptember 29, 2020 at 7:11 amPost count: 8455
Your new MRI notes no compression of any root above the L5 level (“There is no significant canal or foraminal narrowing inferiorly through L4-L5”). There is some displacement of the L5 nerve root due to a seroma-a collection of post-surgical fluid; (“L5-S1: There is postsurgical fluid along the surgical tract into the disc space, which superiorly displaces the right L5 nerve root within the foramen, for example series 3 image 11. There is persistent T1 hypointense material in the epidural space extending along the right S1 descending nerve root, likely reflecting scar tissue”).
If your symptoms are improving to your satisfaction, you can elect to “wait and see”. If however, you have problematic symptoms, you can ask for a needle aspiration of the seroma and an epidural steroid injection to decompress the root and allow some anti-inflammatory consideration.
Dr. CorenmanMASpineptParticipantSeptember 29, 2020 at 7:26 amPost count: 17
Ok thank you. So do you think the degree of slippage on the xrays is so minimal that it shouldn’t be causing any symptoms?Donald Corenman, MD, DCModeratorSeptember 29, 2020 at 7:33 amPost count: 8455
There was no obvious comment about degenerative facet changes at L4-5 but sometimes, radiologists might not pick up on that. The best way to determine if that slip is significant is with flexion/extension X-rays.
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