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  • ffwyfe
    Member
    Post count: 3

    Just a little background as I am new to this site…
    I am a 35 year old female I had a microdiscectomy last year for a herniation I have a transitional segment L5/S1 is sacralized, the level I had the microD on was identified as L3/L4 on one MRI and L4/L5 on follow up MRI and now I am having a TLIF and the numbering is causing a bit of difficulty and I am having major confusion based on my MRI results they show both levels L3/L4 and L4/L5 both with herniations… my spine surgeon told me the operative level was L3/L4 when we spoke in the office, then when I dropped of the MRI disk again so he could review it to decide on approach once I decided to go ahead with surgery (I was trying to stay conservative as long as possible) then the paperwork said L4/L5… so my question is based on the idea that we are going to do the previously operated segment and it is L3/L4 and per the MRI done this year that’s the post laminectomy site, and I also have a herniated disc at L4/L5 per that same MRI, then the next segment down is sacralized should I have the L4/L5 fused as well? Would it cause adjacent level stress or do I just take my chances that it will resolve and go about the single level fusion?… As I understand it there will be addition forces placed on that segment as well as the one above the fusion but if this level already has compromise will that be a problem in the future? I don’t want to have any more surgery and I was reluctant to do this one aside from not being able to enjoy my kids and having a hard time with performing my job duties (I am and RN) I just can’t take the pain anymore and need to do something…. but do I go for the two level and protect that other level or stay conservative? Sorry so long I don’t know how I could shorten it…. Thanks for your time

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    The L5-S1 segment that is sacralized can be called L5-S1 or can be called S1-2 depending upon the circumstances. As long as the reading is consistent, there should be no problem. One common way to discern levels is to note the last movable level. That is, the report should name the last movable level as L5-S1 and describe how that was called L5-S1.

    You have decided to undergo a fusion of your lumbar spine. Is this because you have more lower back pain than leg pain? Is it because you have had already two surgeries to one level and the disc has herniated again a third time? It is because of instability of the level? If those three particular conditions are not present, why are you going to undergo fusion?

    Did you have a workup to determine the pain generators (SNRB or discogram-see website)? Before we can discuss fusion levels and the potential future of your spine, you need to bring more information to the table.

    Dr. Corenman

    ffwyfe
    Member
    Post count: 3

    There are several factors that are contributing to the decision of proceeding with a fusion, reherniation, instability, and there is significant low back pain in addition to the leg pain and numbness… I did have a couple diagnostic epidural injections which identified both levels as causing pain as well as the MRI and CT, no discograms… I had held out as long as possible on the idea of another surgery ordeal but the pain and limitation involved is affecting my life in multiple aspects: I am an RN and have a very physical job (I am an ER nurse in a very busy ER and lucky for me I have not had to do CPR on anyone in a long period of time), I am a full time student getting my master’s degree and doing clinical rotations in conjunction with going to work is getting wearing on my back and legs, and lastly but most importantly I am also a mother of very active twin boys and it kills me that I cannot do the things I want to do with them, playing at the park running around on the beach, just horsing around like boys do… those are what led me to my decision to proceed… now i just need to know how far involved it should be… single to two level? Will there be compromise of the level in between if the level above and below are fused? Should I just agree with the two level or be adamant on the single level and take my chances? I will include my MRI report if that helps…

    FINDINGS: Previously, a transitional vertebra was reported at the
    lumbosacral junction suggesting sacralization of L5. The current
    study reveals the vertebral bodies to be stable in signal and
    alignment.

    T12-L1, L1-L2, L2-L3: No disc pathology. The central canal, neural
    foramina are patent.

    L3-4: Status post left hemilaminectomy. Disc desiccation, large disc protrusion
    which is eccentric to the left. Post-contrast images demonstrate
    enhancement in the left lateral epidural region suggesting the
    presence of scar and/or granulation tissue. Enhancement to the disc
    is noted in the left subarticular/foraminal region. The left neural foramen is significantly
    stenotic, right patent. Central canal patent.

    L4-5: large disc protrusion. No central canal stenosis. Neural
    foramina moderately stenotic.

    L5-S1: Transitional level with sacralization to L5. The central
    canal and neural foramina are patent.
    Impression
    IMPRESSION:

    TRANSITIONAL LEVEL AT THE LUMBOSACRAL JUNCTION THOUGHT TO REFLECT
    SACRALIZATION OF L5. BASED UPON THIS, THE CONUS TERMINATES AT THE
    UPPER MARGIN OF L1.

    STATUS POST LEFT HEMILAMINECTOMY AT L3-4 WITH FINDINGS SUGGESTING
    SCAR/GRANULATION TISSUE IN THE LEFT LATERAL EPIDURAL REGION. DISC
    PROTRUSION AT L3-4 WHICH IS ECCENTRIC TO THE LEFT, DISC PROTRUSION AT L4-5 ALSO ECCENTRIC TO THE LEFT

    Any insight and opinion you can share would be greatly appreciated… all examples given to explain the content of the disc as a jelly donut so in that respect I am concerned that if the two levels surrounding that already herniated disc are fused it would be comparable to putting a jelly donut between two slabs of concrete? or am i mistaken? Thanks for your time

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    You have lower back pain and leg pain. What is the percentage difference between the two? Do you have more lower back pain or more leg pain? If you have lower back pain, do you have more pain with standing and walking or more pain with bending and loading the spine? Is your lower back pain midline or is it off to the side? What activities makes this pain better or worse?

    These are all important questions as there are times that lower back pain could be caused by nerve compression and not originate from the disc itself. This differential could affect the surgery necessary to relieve your pain. Have you had only one prior surgical decompression or two? I would need more information to understand the necessity for fusion.

    If you need a fusion and both L3-5 levels are fused with an already immobile L5-S1, this would constitute three levels in your lower back becoming immobile. There will be more pressure on the L1-3 levels and you would have to reduce certain activities accordingly. I hope you do not plan to take up running, tennis or other impact sports. Better sports would be cycling, swimming, hiking and cross country skiing.

    Dr. Corenman

    ffwyfe
    Member
    Post count: 3

    depending on the position and activity is what affects the ratio of back to leg pain, if I am bending forward I have more leg pain if I am upright and walking or standing in one position too long I have more lower back pain that radiates up into my thoracic area, but the leg pain is lessened with walking and exacerbated by sitting… I feel like I can’t win unless I am laying down and even then the muscle spasms start and I wake up very, very stiff and go to bed in crazy spasm and burning from my lower back to my legs (left greater than right) I am not taking up any sports I used to be a gym rat but not a high impact sports kinda person I just want to enjoy my kids… I understand that would contribute to significant limitation of my spine but would not fusing the level in between that is already compromised cause added stress to in and lead me into another problem? My job is physically demanding and I am afraid I will be back to square one again….

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    Most likely your leg pain with sitting originates from the disc herniations compressing your nerves. Your back pain could originate from the discs which could require fusion but there is a variant of lower back pain that originates from canal stenosis (narrowing of the spinal canal) and one from facet pain. See the section “causes of lower back pain” to understand these variants.

    Long fusions (more than three levels) do require that you reduce certain activities to prevent injury to the discs above. You would effectively have a three level fusion as you have a sacralization of the L5-S1 level.

    There are tests to indicate the sources of lower back pain including facet blocks, discograms and rarely, epidural spinal injections.

    Dr. Corenman

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