[jayd10033]

#36133

Hello Doctor. A brief history: Right L3-4 extraforaminal discectomy c/b postop discitis 3/17/21, C5-7 TDR 11/2/2021, L3-4 XLIF/MIS PSF 2/25/22. No real other diagnosis than degenerative disc disease.
———————————————————————————————————-
I have had persistent dull ache in lower right back, tingling down right, sometimes left, leg and tingling\deep ache in buttock. Tried ablation/two rounds of steroid injections, which only temporarily helped. Now have a scheduled (2/27) surgery for either a microdiscectomy and/or laminectomy at L5-S1 depending on what the surgeon finds when looking at it in the OR. Below is the latest MRI, a re-read by the surgeon indicates the herniation is more central than left or right, and that it is impinging on both sides.

Question is – should I ask for laminectomy no matter what, since there is still a chance after a microdiscectomy that more could herniate and the nerve be left with not much room again? Or is a laminectomy something I should avoid as long as possible? With my history of disc issues, I just have low hopes removing a tiny part of the herniated part will help for a little while, then I’ll be in this position again when it herniates. I appreciate any feedback you might have on this.

MRI 11/15/2023

FINDINGS:

For purposes of this dictation, the last well-formed disc space will be labeled L5-S1.
Redemonstrated, status post L3-4 discectomy, placement of intervening L3-4 metallic artificial disc and posterior instrumented metallic spinal fusion via left-sided interlocking metallic rods transfixed by left sided L3 and L4 pedicle fixation screws. Stable findings.

OSSEOUS STRUCTURES: No compression fractures. No destructive marrow processes or marrow edema.

ALIGNMENT: Redemonstrated, nonspecific straightening.
Redemonstrated, grade 1 retrolisthesis L2-3.

SPINAL CORD AND CONUS MEDULLARIS: Conus medullaris is at T12-L1.
No enhancing mass lesions, abnormal signal or abnormal enhancement is seen involving the included distal thoracic spinal cord, conus medullaris or cauda equina nerve root sheaths. No intraspinal masses.

PARASPINAL AND INTRA-ABDOMINAL SOFT TISSUES: Unremarkable.

INCLUDED THORACIC SPINE AND SACRUM: Unremarkable and unchanged.

DISCS: Redemonstrated, mild L2-3 spondylosis with disc space narrowing, endplate Schmorl’s nodes and anterior osteophytic spurring.

The following axial levels are imaged and detailed below:

T11-12 through L1-L2: No disc bulging or herniation. No spinal canal or foraminal stenosis. Stable findings.

L2-L3: Uncovering of the disc by spondylolisthesis. Redemonstrated, nonenhancing disc bulging with mild thecal sac flattening and lateral recess spinal stenosis. No significant foraminal narrowing.

L3-L4: No disc bulging or herniation. No spinal canal or foraminal stenosis. Stable findings.

L4-L5: No disc bulging or herniation. No spinal canal or foraminal stenosis. Stable findings.

L5-S1: Interval development of a mild/moderate, enhancing, broad-based central leftward disc herniation, new left greater than right lateral recess spinal stenosis and mild impingement of descending left and abutment of the descending right S1 nerve root sheaths. No significant foraminal narrowing.

IMPRESSION:
1. Interval development of mild/moderate size broad-based central leftward enhancing L5-S1 disc herniation, new left greater than right lateral recess spinal stenosis and mild upon the descending left and abutment of descending right S1 nerve root sheaths. Intradiscal enhancement suggests fibrosis.
2. Otherwise no significant interval change.
3. Redemonstrated, status post L3-4 discectomy, L3-4 metallic artificial disc and left-sided posterior instrumented metallic spinal fusion.
4. Redemonstrated, grade 1 retrolisthesis L2-3.
5. Redemonstrated, mild L2-3 spondylosis with nonenhancing mild disc bulging with mild thecal sac flattening and mild lateral recess spinal stenosis.
6. Otherwise no significant interval change.

Thank you for the opportunity to participate in the care of this patient.

[jayd10033]

#36134

UPDATE: reply from surgeon’s PA on similar query, this makes more sense to me now, but would still be good to hear your thoughts based on MRI and proposed plan.

UPDATE from surgeon’s office:

This procedure (Minimally invasive laminectomy) is basically almost the same as the first lower back surgery you had–the Microdiscectomy. It just differs in that we do not remove an extruded disc fragment. We just remove the little portion of the bone that is pinching the nerve. So it is actually a smaller procedure than the Microdiscectomy and you do not have as many postop restrictions. It is outpatient so you will go home the same day. Just no BLT for 2 weeks after surgery then get you into PT. But you can do the elliptical, bike, walk on the treadmill 2 weeks after surgery. You can lift your daughter but I would be careful in the first several days/week after surgery and use proper lifting techniques:)

We would only remove something at the time of the procedure. If it is just a broad-based disc bulge we don’t remove that because we would have to cut a hole in the disc and that could cause more disc material coming out after surgery and having to go back in. When we get down there and if we see any extruded material we will remove that and if there is already a hole in the disc we will interrogate that but we try really hard not to create our own hole in the annulus.

[Donald Corenman, MD, DC]

#36135

Quote “This procedure (Minimally invasive laminectomy) is basically almost the same as the first lower back surgery you had–the Microdiscectomy.” What procedure did you undergo initially?
I am confused. The radiologist L3-L4: No disc bulging or herniation. No spinal canal or foraminal stenosis. Stable findings”. Then the radiologist says “Redemonstrated, status post L3-4 discectomy, L3-4 metallic artificial disc and left-sided posterior instrumented metallic spinal fusion”. Did you have a fusion at L3-4?
The radiologist then says “mild/moderate size broad-based central leftward enhancing L5-S1 disc herniation.” According to the radiologist, you have a disc herniation that needs to be trimmed. The fact that the PA notes they are going to leave the disc alone makes no sense to me. If your problem is nerve compression, why leave a large compressive element? Also, there has to be a laminotomy on the side (or sides) of the compression. You don’t need a laminectomy (removing the entire lamina).

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.

[jayd10033]

#36139

Hey doc – a few years ago at a different level I had an L3-4 microdiscectomy, a surgery that introduced an infection that required PICC line antibiotics. You were greatly helpful to me during that time with many answers on the forum. Thank you. The disc at that level eventually so deteriorated and causing me pain (bone on bone almost) that I had a fusion. There have been no other issues at that level.

The plan with the L5-S1 surgery seems to be to remove any extruded disc material, and also to do a procedure to remove part of the bone to allow the nerve more room. I will inquire about a laminotomy vs. laminectomy.

Thank you for the reply!

[Donald Corenman, MD, DC]

#36141

Keep us posted please.

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.

[jayd10033]

#36168

Hi Doctor. I had the procedure today. Feeling pretty good for day 1. I don’t have any questions today but you asked to keep you posted, so here is the post-op report! Thank you so much for always being so generous with your analysis and guidance.

OPERATIVE REPORT

PREOPERATIVE DIAGNOSES:
1. LEFT L5-S1 HERNIATED NUCLEUS PULPOSUS.
2. BILATERAL L5-S1 LATERAL RECESS STENOSIS.
3. BILATERAL L5-S1 LUMBAR RADICULOPATHY.

POSTOPERATIVE DIAGNOSES:
1. LEFT L5-S1 HERNIATED NUCLEUS PULPOSUS.
2. BILATERAL L5-S1 LATERAL RECESS STENOSIS.
3. BILATERAL L5-S1 LUMBAR RADICULOPATHY.

OPERATIONS:
1. LEFT L5-S1 LAMINOTOMY AND DISKECTOMY.
2. RIGHT L5-S1 HEMILAMINECTOMY WITH PARTIAL MEDIAL FACETECTOMY.
3. USE OF INTRAOPERATIVE MICROSCOPE AND MICROSURGICAL
TECHNIQUES.
4. INTERPRETATION OF INTRAOPERATIVE FLUOROSCOPY.

ANESTHESIA: General

TYPE OF ANESTHESIA: GENERAL ENDOTRACHEAL ANESTHESIA.

ESTIMATED BLOOD LOSS: MINIMAL.

HARDWARE: NONE.

DRAINS: NONE.

CONDITION: stable

FINDINGS: LEFT L5-S1 HERNIATED NUCLEUS PULPOSUS (PROTRUSION WITH IMPENDING EXTRUSION), BILATERAL LATERAL RECESS STENOSIS.

PROCEDURE IN DETAIL:

The patient was transported from the preoperative holding area to the operating suite where general anesthesia was administered by Department of Anesthesia. Sequential compression devices were placed on the bilateral calves for DVT prophylaxis. Perioperative intravenous antibiotics were administered.

POSITIONING: The patient was positioned prone on the Jackson table utilizing the Wilson frame with care to position the cervical spine in appropriate position and the axilla free of compression. All bony prominences were well padded as well as the ulnar nerves of the elbows.

PREPPING AND DRAPING: The patient was prepped and draped in the usual sterile fashion and manner utilizing ChloraPrep solution and Ioban draping.

INCISION AND EXPOSURE: Following surgical time-out, radiographic localization in both AP and lateral planes utilizing fluoroscopy (interpreted intraoperatively by the surgeon), a 22-mm incision was made longitudinally in the midline over the L5-S1 interspace just to the left of midline. A left paracentral fascial incision was performed to the left of the L5 spinous process with electrocautery. Sequential tube dilation was the Medtronic METRx system until a 4 cm x 18 mm tube was docked on the left side on the L5 hemilamina. A marker was placed underneath the lamina and a cross-table fluoroscopic radiograph was taken confirming the appropriate level. This was interpreted intraoperatively by the surgeon. At this time, the operating microscope was brought in to the sterile field and microsurgical techniques were utilized for the remainder of the case.

LAMINOTOMY: A laminotomy was performed utilizing the motorized high-speed bur and completed with Kerrison rongeurs. The ligamentum flavum was resected at the L5-S1 interspace on the left side. At this time, the S1 nerve root was identified along with the thecal sac.

LEFT L5-S1 DISKECTOMY: The S1 nerve root and thecal sac were gently mobilized and protected with a nerve root retractor. A disc protrusion was identified underneath the medial aspect of the traversing S1 nerve root and the thecal sac. At the apex of the protrusion it appeared that and extrusion was imminent. A small transverse annulotomy was performed with a #15 blade scalpel. Gentle pressure was applied to either side of the annulotomy with the #8 suction and small straight ball-tipped probe and the disc herniation readily extruded through the annulotomy. The disc base was explored with a small ball-tipped probe as well as the micro pituitary rongeur and additional fragments were removed. A maximal amount of healthy disk material was maintained. The disk space itself was irrigated with antibiotic irrigation and any free and loose fragments were also removed. At the termination of the decompression, a long ball-tipped probe was utilized to palpate the ventral aspect of the thecal sac, the exiting L5 nerve root and traversing S1 nerve root. The traversing nerve root was noted to be gliding freely. Hemostasis was confirmed.

RIGHT L5-S1 HEMILAMINECTOMY WITH PARTIAL MEDIAL FACETECTOMY: The retractor tube was removed and then attention was turned to the right side. A second separate fascial incision was made to the right of midline and sequential tube dilation was performed until a 4 cm x 18 mm tube was placed clearly visualizing the right-sided hemilamina. A crosstable fluoroscopic radiograph was taken confirming the appropriate level with a Woodson elevator underneath the lamina. The operative microscope was brought into the sterile field again. Soft tissue was denuded from the right L5 lamina. A motorized high-speed bur was utilized to perform hemilaminectomy and partial medial facetectomy. This was completed with 3 mm 4 mm Kerrison rongeurs. The cephalad aspect of S1 was also decompressed and removed utilizing Kerrison rongeurs. At the termination of decompression the traversing right S1 nerve root and thecal sac were noted to be free of further compression. Hemostasis was confirmed. Then, 1 mL of 80 mg Depo-Medrol was instilled into the spinal canal as an epidural injection.

CLOSURE: The METRx tube was removed. The fascia was closed with #0 Stratafix suture bilaterally on both sides of the spinous process. The subcutaneous tissue was closed with 2-0 Vicryl suture. The skin was closed with 4-0 Monocryl Stratafix suture. Marcaine 0.25% was injected. Dermabond and Steri Strips were applied. A sterile bio-occlusive dressing was applied.

At the termination of the procedure, we were informed that all needle, sponge, and instrument counts were correct. The patient was turned supine and extubated by the Department of Anesthesia. The patient was noted to be moving bilateral lower extremities grossly. The patient was transported to the Postanesthesia Care unit in satisfactory condition, having tolerated the procedure well without incident or complications.

WOUND CLASSIFICATION: CLEAN.

SPECIMENS: NONE.

COMPLICATIONS: NONE.

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