Viewing 6 posts - 1 through 6 (of 14 total)
  • Author
    Posts
  • MASpinept
    Participant
    Post count: 17

    Hi Dr. Corenman,

    I’m hoping to get your opinion on my latest situation; i had posted a few questions in the fall/winter in regards to my L5-S1 TLIF recovery, since that time i have been doing a lot of rehab, strength training and exercise to try to get my legs (and whole body) back into athletic shape. I have achieved this in all areas except on the right lower side. Prior to the fusion i had 2 failed right sided hemilaminectomies for occlusion of the L5 and S1 nerves, the surgeries led to spondylethesis which was repaired during the TLIF. At some point (not sure if this was present prior to surgery or if it was after) i started noticing my right hip and muscles of the upper leg felt weak, i did bring it up to the surgeon but he said the post op MRI looked clean; no neuro exams have been done by the surgical team since the surgery d/t covid (telehealth follow ups). So fast forward to current times, i returned to physical therapy, someone who did a very thorough neuro eval, and he agreed that many muscle groups on the right side going up as far as L1 are weak with a comparison of 4/5 on the right to 5/5 on the left. Once again i brought this to my surgical team’s attention and pushed for further work up to be done. I have an appointment with the physiatrist tomorrow, who is part of the spine group where my neursogeon is. I had made this appointment to get their opinion on the state of my leg and to see if any supports/bracing would be needed as the weakness very much affects my biking, running, swimming ability by fatiguing easily. I find i cannot feel certain muscle groups when i work out or when i am planting my foot down/rotating my leg. I have asked for an EMG to compare to the one done from last year prior to the TLIF, though i am not sure they looked beyond the levels of L5/S1. I do have some scoliosis but it hasn’t come up as an issue with the surgical team. My latest xrays show that the fusion is progressing exactly how it should be at this time, per the surgeon. There is some atrophy in the right leg as well. The response from the surgeon was basically lets see what the physiatrist says and then we will go from there.

    I’m wondering if you have any thoughts as to what could be cause issue to develop on one side at higher levels than the fusion. I have tried to be patient and do everything possible to get myself in the best physical condition possible but i am again growing concerned. I’m only 34 and i’m nervous that things may have snowballed, i work in healthcare and i see many things that get brushed off or go unnoticed and i’m not interested in having this happen to me as i feel it with further any degree of disability.

    What do you think? Many thanks in advance for being such a wonderful source of guidance and information.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8468

    “I started noticing my right hip and muscles of the upper leg felt weak, i did bring it up to the surgeon but he said the post op MRI looked clean; no neuro exams have been done by the surgical team since the surgery…..Prior to the fusion i had 2 failed right sided hemilaminectomies for occlusion of the L5 and S1 nerves. The surgeries led to spondylethesis which was repaired during the TLIF”.

    The levels of nerve compression were of L5 and S1 roots. The L5 root connects to the gluteus medius and sometimes glut max muscles, both highly important in walking and biking. If the medius is weak, you cannot lift up your pelvis on the opposite side when weighted (walking-called a Trendelenberg gait) and if the maximus is affected, your down pedal stroke would be less powerful on that side.

    An EMG and consult with a neurologist would be helpful. I assume your new imaging demonstrates no further compression.

    Dr. Corenman

    MASpinept
    Participant
    Post count: 17

    I actually have not have an imaging recently, the last MRI was about 11 months ago. I did see the neurologist today and he felt based on the exam there could be some adjacent segment issues. He is ordering an MRI and will do an EMG. Does ASD happen this quickly? I’m wondering now if another surgery is in the near future. Thanks

    MASpinept
    Participant
    Post count: 17

    Hi,

    Below are my ct results. Is this typical for 11 months post tlif? My pain continues to be an issue, most right leg pain and it is almost as bad as it was pre surgery. I also have more noticeable bilateral leg pain and numbness/tingling. It seems like as the weeks go on activities that were once tolerable are becoming more painful (swimming, biking, driving). I have an mri and emg next week. Thanks
    Document: CT LUMBAR SPINE WITHOUT
    PROCEDURE: CT 0054 CT LUMBAR SPINE WITHOUT CONTR Jul 9 2021 11:29AM
    CLINICAL INDICATION: ENCOUNTER FOR FOLLOWUP DOSE: dlp; 768.87
    CLINICAL INDICATION: Postoperative follow-up. Status post TLIF on 8/5/2020 with worsening back pain, right worse than left leg pain, bilateral leg numbness and tingling with standing, and worsening of symptoms with activity per the patient questionnaire.
    TECHNIQUE: Helical CT of the lumbar spine without contrast was performed according to routine protocol. The helical data set was reformatted in the sagittal and coronal planes. Additionally a 3-D model of the data set was performed at an independent workstation. Dose reduction techniques were utilized including mA and/or kV adjustment.
    COMPARISON: Lumbar spine radiographs from 8/7/2020 and 4/20/2021. Lumbar spine MR from 8/21/2020.
    FINDINGS AND IMPRESSION:
    Intact L5-S1 fixation construct in place with bilateral pedicle screws, vertical rods, and interbody device. No significant periprosthetic lucency to indicate component loosening.
    At the left L5-S1 facet joint, there is bony bridging that appears to be progressing towards osseous union. No joint gas to suggest excess motion. No posterolateral osseous union on the right.
    At the L5-S1 disc space on the right, there is bony spicule formation that may span the entire height of the disc space. There also appears to be developing bony bridging at the site of the interbody device, although hardware related artifact precludes accurate assessment. No intervertebral disc gas to suggest excess motion.
    Vertebral body heights are preserved.
    Alignment is maintained.
    Disc heights are preserved at the noninstrumented levels.
    T12-L1: No significant abnormality. Canal and foramina are patent.
    L1-L2: No significant abnormality. Canal and foramina are patent.
    L2-L3: Mild facet degenerative change bilaterally. Patent canal and foramina.
    L3-L4: Mild right facet degenerative change. Patent canal and foramina. L4-L5: Shallow posterior disc bulge. Mild left facet degenerative change.
    Patent canal and foramina. Page 1 of 2 L5-S1: Status post bilateral pedicle screw fixation and right-sided TLIF, Page 1 / 2
    as detailed above. Canal and foramina are patent.

    L3-L4: Mild right facet degenerative change. Patent canal and foramina.
    L4-L5: Shallow posterior disc bulge. Mild left facet degenerative
    Patent canal and foramina.
    L5-S1: Status post bilateral pedicle screw fixation and right-sided TLIF, as detailed above. Canal and foramina are patent.
    Postoperative changes at the dorsal soft tissues. Imaged retroperitoneum is unremarkable.
    NUMBER OF IMAGES: n

    MASpinept
    Participant
    Post count: 17

    Hello again,

    I wanted to give an update; the MRI didn’t show any stenosis or compression, just further arthropathic changes on L4-L5 (right above the tlif) with new bilateral effusions. Unfortunately i have not been able to get an answer regarding the fusion status, the only answer i received was that the hardware shows no signs of loosening. I’m just a little concerned because based on my research there should be more of a solid fusion by the 1 year mark (BMP was used). I’m starting to think there may be some malalignment since so many of my symptoms are positional and activity related, prior to the TLIF i did have a slip with a pars fracture on the right side of L5. I do have mild levoscoliosis in the lumbar spine, have been told i only have 4 lumbar vertebrae, and immediate post op images from the tlif last year commented on stepwise lethisis of the L spine (particularly retro at L4-5) but again all this structural information has been brushed off as a reason for any symptoms since surgery. I have an EMG scheduled for next month. Please let me know your thoughts on this when you get a chance. I do think i would like to schedule a long distance consult/review with you in the near future once we get the EMG results and the neurologist’s thoughts. I’m wondering if ortho spine would have more of a focus on spinal structure vs only looks for for nerve compression. Thanks for your time!

    Donald Corenman, MD, DC
    Moderator
    Post count: 8468

    Its surprising that the radiologist did not comment on fusion status with a CT scan. They might not comment if it was an MRI but a CT scan tends to be definitive. What are your current symptoms? See: https://neckandback.com/conditions/how-to-describe-your-history-and-symptoms-of-lower-back-and-leg-pain/.
    A long-distance consultation might be necessary.

    Dr. Corenman

Viewing 6 posts - 1 through 6 (of 14 total)
  • You must be logged in to reply to this topic.