Viewing 6 posts - 1 through 6 (of 6 total)
  • Author
    Posts
  • BIG{HIL
    Member
    Post count: 3

    I had a TLIF Jan 2010 due to DDD, Protrusion and annular tear. I had a lot of lBP, sciatica, hip and buttocks pain. After 6 months of PT and follow ups my surgeon finally sent me back to PM b/c I was in worse pain in my hip, buttocks area. I did have union at the l5-s1 where the fusion was done. PM and the neurosurgeon came to an agreement that all my pain was being generated from my L Si Joint. Prior to the fusion a discogram was done followed by CT and confirmed the tear and IDD at l5-s1 was my pain generator. They did 2 diagnostic SI injections and I had instant relief for about 4 hrs then the same pain returned. They did 1 with cortisone and then a RFA after a lateral branch block. I only got temp relief. I went back to PT and after 16 visits I was in agony. So PM said I had 2 options a take pain meds or see a Ortho Spine specialist. After seeing the Ortho doc he recommends a SI fusion with IFUSE on the left side. So if this is my “pain generator” why would the discogram be positive? This surgery is relatively new and I am concerned the fused spine and the L SI Joint being fused will make the R joint have dysfunction next. Do u know any surgeons who do the IFUSE by SI BONE? Are the results any good? I just want any advice or opinions from someone not local.. I also have started to have severe pain in my neck, shoulders and only occasionally in my forearms. I had a MRI 4 yrs ago and it showed diffused annular bulge that extends into the foramina. The foramina may be narrowed and moderate facet hypertrophy no canal stenosis. This was at c5-c6. My pain and stifness has gotten a lot worse since 2008. It seems to have worsened since my back was fused if this makes sense? I can not sleep from the pain in my back and now my neck burns when I lay down and at times my face will actually twitch which is annoying. Everything is on my left side. Is these symptoms of something that has maybe gotten worse in my neck? Due to my SI Joint and TLIF I have really not payed my neck much attention until the last 6 months or so.. Any insight, suggestions or advise would be greatly appreciated..

    Donald Corenman, MD, DC
    Moderator
    Post count: 8436

    To summarize, you had hip, buttocks and lower back pain- I assume on the left side. You had a workup with discograms which identified L5-S1 as the level that caused pain. Did you also have some nerve root compression from disc herniation or from foraminal stenosis on the left (see website for description)?

    After surgery, I assume a CT scan was performed as the surgeon told you that you have a solid fusion. Unfortunately, the symptoms are even somewhat worse than they were before surgery. Are the symptoms the same as before surgery but worse or different than before but worse? Without a CT scan, how did the surgeon know if there was a solid fusion?

    Sacroiliac joint origin of pain is unusual after a TLIF at just the L5-S1 level unless there was a bone graft taken from the sacroiliac joint region. Did you have a graft taken here? Most times, sacroiliac joint pain is referred from L4-5 or L5-S1. To make sure it is the sacroiliac joint as the pain origin, ask if the surgeon will consider a selective nerve root block (SNRB) at L5-S1 on the left. If that gives you no relief, then the sacroiliac joint can be considered the pain generator. However, if that block gives you relief, your pain most likely originates from the L5 nerve in the foramen at L5-S1.

    There are occasions that the L5 nerve can be irritated with a TLIF performed on that same side (extremely rare if the TLIF was performed on the opposite side). If the SNRB gives relief, a new MRI or even CT is indicated to look for something called a BMPoma or a bone spur. If the surgeon used BMP- bone morphogenic protein (and many do) and there was some growth of an amorphous mass (BMPoma), then it may be indicated to surgically remove the instrumentation (assuming a solid fusion) and clean out the foramen to decompress the nerve.

    Fusion of the SI joint for pain reasons is unusual but you do have a diagnostic block and a failed rhizotomy behind you. There is a procedure called prolotherapy for the SI joint where a substance injected into the joint is designed to cause fibrosis of the joint. I have seen some reasonable results but be careful of this therapy.

    If none of the above yield relief, fusion of the SI joint could be considered. I have never fused an SI joint except for trauma so my experience would not help you here.

    Do not confuse the neck and arm pain as being related to your lower back.

    Dr. Corenman

    BIG{HIL
    Member
    Post count: 3

    Thanks for responding. Yes all my pain was on the L side. After my fusion I did and have had a total of 2 cts and 2 flex xrays and they showed 85-90% union. Prior to sugery I did have a 5mm herniation or they called it a protrusion left paracentral. My annular tear was severe enough the radicular pain was from the chemicals in the annulus leaking they say. I am being told the DI Joint was more of an issue than they originally thought. My pain now is worse than before the fusion in the low left back, hip and groin. It was there before the fusion. The mid LBP and sciatica the fusion has resolved that somewhat.. I did have BMP inserted in the cage and no bone graft. The PM has done a Lateral branch block however.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8436

    I am unclear as to the meaning of 85-90% union. Does this mean complete union or “you are almost there” type of union? This can make a big difference. Use of BMP with increased pain in my practice means a new MRI is warranted to look for the “BMPoma”.

    You have not had a SNRB of the L5 root on the left yet. In my practice, that would be the next step along with an MRI. If the patient would get great relief, I would focus more on the L5 root than the SI joint. Again- if good relief (depending upon the MRI findings), I would consider removing the instrumentation and exploring the nerve root before considering fusion of the SI joint.

    If the SNRB gave no relief or the MRI demonstrated no compression or adhesions of the L5 root, then I would consider a fusion of the SI joint.

    Dr. Corenman

    BIG{HIL
    Member
    Post count: 3

    I say 85-90% in that it was at that at my last CT, so close to being there. I will be sure to address the isssues u have brought up. I am grateful to have gotten great advice. I am not sure what u meant by “BMPoma”? I will post if I have any updates.. Thanks!!

    Donald Corenman, MD, DC
    Moderator
    Post count: 8436

    BMP or bone morphogenic protein is a synthetic human protein that causes your own stem cells to turn into bone cells. There are rare occasions that the BMP can “leak” out of the site is was intended for and seep into other areas. At a lower concentration, this BMP seems to cause fibrous tissue, cartilage and amorphous “granulation tissue” to form. This can irritate or compress the nerve root.

    If the approach for the TLIF was on the left side, an MRI at least 6 months after surgery can “spot” this “BMPoma”. Surgery to decompress the nerve seems to give nerve root relief in about 50% of the cases. If the CT notes solid fusion, then the instrumentation can be taken out at the same time.

    Dr. Corenman

Viewing 6 posts - 1 through 6 (of 6 total)
  • You must be logged in to reply to this topic.