[HG in Houston]

#7679

Back in October 2012 I noticed that I was no longer able to walk on my right heal and I also noticed that my right quad was smaller than my left. I was went to see an orthopedic.

By background for over 15 years I have had bulging muscles deep in my right buttock which i usually dealt with with ice and heat. The pain is worse standing for long periods of time or even sleeping. In 2001 I was in a bicycle accident where I fell on my right hip and had a significant hematoma. To this day the outside of my right hip still has some swelling.

After seeing the ortho he said I had foot drop and sent me for an mri and referred me to the ortho surgeon. The MRI came back with bulging disc at L5 S1 but after physically examining me the surgeon said the herniation was not that bad and based on my symptoms he expected to see a bigger bulge with a pince of the nerve. Mind you I do not expereince sever sciatic pain like electricity. It is more heavyness and some numbness down the right side of the leg.

The surgeon referred me to get neuro to get an emg. She confirmed that the peroneal nerve was pinced off and belived it was the L5/S1.

I scheduled another appointment with the orth but also went to see a team of chiropractors to get their thoughts. They focused on the pain in the buttock and believe I have piriformis syndrome which I now know all these years my butt pain had been piriformis.

I am wondering what approach I should take. Should I get an injection of the piriformis to try and rule it out or an injection in the back t to try and rule it out? If the herniation is not that bad should I consider surgery?

I feel a sense of urgency as I am praying like hell that I can get my regular walking back and fear damage if I wait to long.

[Donald Corenman, MD, DC]

#7681

Your account is somewhat confusing. The EMG noted a peroneal nerve involvement. This nerve can be trapped at the outside of the head of the fibula bone right below the knee. Did this neurologist note entrapment or a true L5 radiculopathy?

The disc bulge at L5-S1 typically compresses the S1 nerve which leads to weakness of the calf muscles and the inability to walk on your toes-not foot drop which is associated with the L5 (and occasionally the L4) nerve. Do you have a far lateral disc hernation which is not uncommonly missed by a reading of the images?

Piriformis syndrome is exceedingly rare and commonly over diagnosed. Nonetheless, a fall onto the buttocks can cause this problem. Piriformis syndrome is however almost never associated with motor weakness.

If the nerve is compressed and you have motor weakness, it is my opinion to undergo surgery to give the nerve the best chance to recover. See the section on the website under “Conditions”/”Nerve injuries and recovery” to understand how nerves can heal.

On the other hand, I am not sure that you have an obvious diagnosis. Maybe another set of eyes on your condition can be helpful.

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.

[HG in Houston]

#7683

Thanks Dr. She said she believed the foot drop was being caused by the disc issue but she did have me do an MRI to rule out a tumor or some other object entrapping the nerve below the knee.

I been reading your forum and have realized something. I noticed i have also been limping but I thought it was caused by footdrop. However I did raises on my toes as instructed and I started strong but after 5 or so can no longer lift my heel.

So right now I am simultaneously experiencing both foot drop and a calf issue. That does not seem to be supported by the MRI which is a small bulge at L5/S1.

I am see my orthosurgeon in the morning and will be discussing results of the emg and next steps.

The neurologist said she was going to suggest a conservative approach meaning PT or epidural but it sounds like I might need to be more aggressive. I am just concerned about my surgeons reaction that the mri did not look that bad at least bad enough to support the symptoms.

[Donald Corenman, MD, DC]

#7687

To have foot drop (L5 or possibly L4 nerve) and have gastroc/soleus weakness (S1 nerve) with a “small herniation) at L5-S1 does not fit with a mechanical compression of both nerves. I would look to the neurologist to come up with an explanation as this compilation of symptoms with your dictated imaging findings does not make sense for mechanical compression of the nerve root.

In order to consider surgery, you need to have a surgical pathway that makes sense. Either the imaging findings are incorrect or there is another explanation for your current weaknesses.

You need an advocate to search the “small stuff”- a call to the neurologist to explain her findings, a re-review of the imaging to look for undiscovered findings and another thorough physical examination to confirm weakness findings.

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.

[HG in Houston]

#7688

Thanks Dr. a few more facts.

MRI of lower right leg was fine.

I have my MRI report and here is what it says:

Right Leg Weakness

Multiplanar examination was performed without contrast. Sagittal images demonstrate degenerative narrowing of the disc space at L5-S1. There is heterogeneous fatty bone marrow infiltration throughout the lumbar spine and sacrum. Please correlate clinically for metabolic changes and osteopenia.

L5-S1:
There is a broad based right paracentral/foraminal disc protrusion resulting in right lateral recess and foraminal stenosis. Please correlate clinically for right L5 and S1 radiculpathy. There are facet joint degnerative changes bilaterally

L4-L5:
Mild facet joint degenerative changes

Same for all the rest.

Dr. said either surgery or do nothing.

[Donald Corenman, MD, DC]

#7689

The MRI report does indicate both lateral recess stenosis and foraminal stenosis are present. These two narrowed regions together could compress both the L5 and the S1 nerves. The radiologist did not use modifier words (mild, moderate or severe) and you report the surgeon was not too impressed with the imaging findings.

Possibly a consultation from another surgeon might be in order to help figure this out.

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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