[tpgolf59]

#20597

Hi Dr. Corenman,
Thank you first for all the time you’ve spent with this forum and helping many individuals.

I’m currently struggling with whether or not surgery would be beneficial given my condition. A bit of a background – I am a fit, 29 year old male who about 15 months ago developed fairly significant nerve pain in the left upper thigh/buttocks region (classic sciatic pain when straightening leg). At the time I was not educated about how severe disc herniation can become and continued to be active in golf and weight training. About 3 months after this, one morning I was simply bending over when the disc herniation must have gotten significantly worse. I had pain so severe I was bedridden for 2 days. I was prescribed a short dose of Prednisone which knocked out nearly all the pain but noticed I was dealing with a problem when I was walking which turned out to be weakness in my calf. I could not rise up on the toe. I was able to have an MRI done 2 weeks later which confirmed a large paracentral extrusion impinging the S1 nerve root. I also have a rupture at L4/L5 but it is asymptomatic in terms of weakness and paresthesias.

The surgeon I met with during this time suggested that it might be best to watch things and wait on surgery considering each week it seemed like I was getting a little stronger in the calf muscle and not worse. At this time I also had numbness on the outer sole of the foot into the last 2 toes. Definite loss of some muscle bulk in the calf was also observed.

Over the course of the next 4 months I had 2 EMG’s which showed improvement in the muscle recruitment which suggested to continue trying conservative treatment. During this time I went from barely being able to walk around the block to being capable of walking any distance.

About 6 months from the significant rupture I had regained over 90% of the strength in my calf and the muscle has actually gained some of its bulk back. My concern started to shift from muscle weakness to the growing pain/burning in my foot that had developed instead of the numbness. During this entire period the sciatic pain was very minimal and intermittent.

Now about 12 months out I am mainly left with significant burning on the sole of the foot and the majority of the function of my calf although with occasional bad cramping. I was able to get another MRI which showed that the large herniation had shrunk very slightly but was definitely still significantly compressing the nerve root. I feel like I could resume some of my old activities and become more active but I am still very concerned about the herniation becoming worse if I push things. The one thing that has me leaning towards trying surgery is that on days I try to “push” a workout or things a little harder the burning seems to generally be slightly worse the next day and it feels like there is sometimes slightly more pain/tightness in the upper left thigh/buttocks area.

I met with the surgeon again last week and he kind of left things up to me saying that if he did the microdiscectomy, the likely scenario is that he will free up the nerve root but the foot burning and pain might still persist. He said there is a chance that it could still help and a small chance that going and messing with things in there could make things worse and I could have more back pain eventually. He is in the camp that a lot of the damage happened during the initial blowout and the body can adjust to the nerve pressure over time. He said he would have operated initially if I had significant leg/sciatic pain and was getting worse. It might also be worth noting that 2 months ago I tried a transforaminal epidural injection at this level and maybe only saw a little improvement in the foot pain the day of the injection.

I guess the bottom line is I want to get back to being as active as possible and hopefully playing somewhat decent golf again and considering I have somewhat of a constant pain in my foot, I’d greatly value your recommendation on what approach you would recommend. I guess it comes down to the risk of getting worse with surgery to the benefit of removing the pressure of the nerve. Even if the foot pain did not improve, I’d still be happy if I was able to be a little less nervous about the herniation getting worse and causing more bad problems, however my surgeon’s opinion was that retroactive thinking like that shouldn’t influence my decision.

Again thank you for all your help and all the time you put into this. It is wonderful.

[Donald Corenman, MD, DC]

#20602

I tend to push surgery for motor weakness as my studies indicate better outcomes in terms of motor recovery and less pain after a microdisectomy. I am happy that your motor strength has recovered but you still have root compression and may have developed chronic radiculopathy (burning can be a symptom of this). Do you have allodynia (painful electrical distressing symptoms after a light stroke of the skin of the foot)? This goes along with burning as an indication of chronic radiculopathy.

If you still have symptoms one year after this hernation, it is my opinion to decompress the nerve root. The chances of “getting worse” are slim and the chance of some improvement is reasonable.

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.

[tpgolf59]

#20605

Thank you Dr. Corenman for such a prompt response and I appreciate your opinion and insight.

Yes, I would definitely say my symptoms could be described as having allodynia. For example, the burning tends to be far greater when I have something on my foot such as a sock or shoe, and the sole of my foot feels the best when nothing is resting on it. I also tend to every so often get a few short “zings” or nerve pulses throughout the sole of my foot when I am shifting position in a chair for example. Massage helps the pain.

This could without a doubt be more of a chronic pain from nerve injury but like you stated and my surgeon also suggested, the chances of some improvement are reasonable enough to warrant decompressing the nerve root. I’m going to schedule to go through with the procedure and will let you know how things turn out for a case such as this.

Once again thank you for the response. If you have any suggestion on what might be best to treat the nerve pain being that it is chronic after decompressing the nerve I’d also appreciate it.

[Donald Corenman, MD, DC]

#20609

There are medications called membrane stabilizers. See the section on medications to understand these. These meds are standard treatment for chronic nerve pain. The two most common ones are Lyrica and Neurontin. Ask your surgeon about these.

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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