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#23437

I am just now able to write you again as I have just now had another MRI with and without contrast. I was turned down by insurance for the MRI but was finally approved. I saw the MRI DVD and it appeared to me that the L4/L5 disk was yet again out of the vertebrae. The cross sectional view did not to my untrained eye show herniation so I was somewhat optimistic that I hadn’t. I did see a white mass a bit aways from the disk area and was thinking it was perhaps either a seroma as you referenced or a disk fragment.

I called the NS office to see if they had gotten the radiology report. The NS through his secretary told me that I had not re-herniated. Said the white mass area I mentioned was fluid (he had referred to it as “juice”) which was typical after having a surgery. The sciatica is much less starting only yesterday but it feels as if I have a 50 lb. weight in my lower back on my right side (the surgical side). I’m very stiff and have to walk pretty slowly. I am hoping this is just muscular in nature and that I am finally on the mend.

Couple of things mentioned in the radiology report.

“There is prominent edema and a fluid collection in the laminectomy bed at L4/L5 with enhancement. There is disc desiccation at other lumbar levels. Some minimal enhancement of the endplates at L4/L5 is present which is nonspecific but the T1 weighted images show mild fluid and irregularity as well as fluid in the disk space”. Findings: Postoperative change with laminectomy on the right at L4/L5 with ring enhancing fluid collection in the laminectomy bed as well as some inflammation around the forming right nerve root.

We ruled out infection last week with blood work. I won’t be able to see the NS until 11/23. I’m wondering what is causing the problem now given I was completely pain free for the better part of 6 weeks post op (I am now at 12th week). Is it possible this fluid as referenced above is causing my symptoms? I am thinking that when I see him, he will say this is normal and to give my body time (how much?) to reabsorb it. If it can be aspirated as you mentioned, well I’d sure like to have that done to speed up the time to being pain free and back to work as I sure can’t get to work the way I am now. If so, who can that be done by, the NS or perhaps my neurologist that has provided me the epidural shots pre surgery? Again, my sciatic pain pre op was not terrible and I only had the surgery because of calf atrophy and the pain I had would not allow me to sleep at all at night. Accordingly, I’m not thinking that this is a case of the nerve having to heal itself especially since I was pain free after the surgery.

Thanks again for your thoughts. All the best –Tim

[Donald Corenman, MD, DC]

#23442

You apparently have a seroma ofter surgery. This can cause some compression as well as irritation of the root. With your current symptoms, what I do is to have the seroma aspirated (through an injection) and place some steroid onto the nerve root. I assume the lab values ruled out an infection (P. Acnes infection can look very benign) you have no headaches, there was no dural tear during surgery and this is not a dural leak.

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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#23445

Thank you so much for your reply. I have seen pictures of seromas on the internet which are well encapsulated. My fluid buildup doesn’t seem to be encapsulated (again by my untrained eye looking at the MRI) but rather a prominent white patch without borders. Can it still be aspirated in cases where it is not encapsulated or would I be better off to simply wait and let my body reabsorb the fluid?

Relative to the edema and inflammation, my NS had me on a 12 day prednisone pack which did very little. He then advised me to take two Alleves in the morning and then 2 in the evening. I’ve done that for the past 3 weeks and am starting to be a little concerned about being on such a high dose for so long (kidneys). Would you recommend that I stay on that dose for a while longer given the MRI still shows edema and inflammation?

Finally, I take it to mean that desiccation means that I have several disks that are dried out. I’m guessing that comes with age and degeneration. Any way to rehydrate them? Thanks again. Best –Tim

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#23493

To update, I met with my NS this past week to discuss recent MRI which as previously mentioned showed significant edema and inflammation as well as fluid in the affected disk area and a patch of fluid away from it as. NS said that the fluid was to be expected and that he did not feel that it was compressing on any nerves. He stated that the surgery area is futile ground for infection so he did not recommend aspirating it but rather giving it more time. I told him that the 2 tabs or Alleve both am and pm were not working and that I had concerns about it’s effect on my kidneys. He started me on a three week course of Decadron. I have been on the top dose to start with for 4 days and will be on this dose for 2 full weeks before titrating down on the third week. Don’t feel any progress thus far on the Decadron. I asked him if a ESI might speed up my progress and again, he stated that there is always a risk of introducing infection in this currently fragile area with a needle so he does not recommend it.

Again, the sciatica is gone in both my buttock and leg. No sharp pains in my lower back. I am just crazy stiff in spite of doing hamstring, piriformis, and lower back stretches. I can bend quite well but get back up just as stiff. I am an avid cyclist but I couldn’t run 3 steps to get out of a burning house the way my back feels (like there is a 50 lb. weight in my lower back).

I would think that the Decadron would be having some effect at this point after 4 days if it was going to. Again, I was doing absolutely great up to 6 weeks post op and so it’s hard for me to understand how all this swelling and inflammation developed so insidiously. Do you have any thoughts on this…should I just give this some more time? Thanks again!

[Donald Corenman, MD, DC]

#23494

Seromas do not have to be encapsulated and in fact, will not be encapsulated initially. Your current dose of Aleve is about what a prescription grade dose would be (OTC=440mg for two pills twice a day vs 500mg-one pill twice a day for prescription). The Decadron is a strong steroid and I generally only give it in 4-5 day bursts.

I am concerned that your back is “tight” but your leg pain is gone. This is generally good for knowing that there was good decompression of the nerve root but worries me about a potential infection. As I noted before, P. Acnes is a skin organism and can infect a surgery due to it’s living in the sweat glands. If you are still very stiff and achy in your back after about 3 months, these symptoms could certainly be from degenerative disc disease which happens in about 5-10% of patients but could also be an infection. The problem is that on steroids, these medications can drop your lab numbers (CRP and ESR) but maybe you should ask for a lab test with CBC/CRP and ESR just to make sure.

If there is any question, an aspiration of the fluid and cultures sent (P. Acnes takes at least 11 days to grow in culture) would be a step to take.

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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#23495

To be clear, I had blood work done just prior to having the last MRI (with contrast) done which at the time ruled out infection. I then switched from the prescription grade dose of Alleve to the Decadron. My NS has me taking 1.5 mg t.i.d for two weeks and then .75 b.i.d. for the final week. The Alleve was discontinued. I’m 56 y/o so I wouldn’t be a bit surprised to find that I have some degeneration going on in the area.

Would the blood work I had done not also rule out the P. Acnes? If not, would it be safe to simply take the treatment for it (what would that be?) rather than going through the risk of infection by introducing a needle for the aspiration and waiting on the culture to grow for the 11 days? Also what are your thoughts on the Decadron regimen I am on. Today will be my 5th day on it and I believe I woke up this morning feeling a bit better, perhaps it is starting to work. Many thanks again!

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