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#6850 In reply to: My Condition and Recommendation |
Your condition can continue to degenerate but there is only a slight chance that a severe flair-up will cause substantail increase your pain. Generally, pain waxes and wanes and your activity level will be in command of the intensity of your symptoms.
If you only needed a one-level fusion, you would not notice much if any restriction of range of motion. A two level fusion causes more need to restrict activities. Due to your mildly degenerative discs above, twisting impact activities might cause symptomatic upper level disc degeneration. Sports like tennis and skiing should be restricted if a two level fusion is necessary.
Driving, standing or sitting generally does not cause significant loads on the back.
See the section on “When to have lover back surgery” on the website to understand timing of surgery.
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.#6843 In reply to: Lumbar Foraminal Stenosis: Discrepancy in MRI Impressions |Dr. Corenman,
Much appreciated for the quick reply. I did fail to denote that I currently have standard X-rays of my lumbar spine, taken a few days prior to the MRI. I’ll send those along with the MRI materials… The X-rays are lateral and AP views, but do not include flexion images. I’ll request a few by my attending PM anesthesiologist.
While neither surgeon mentioned arachnoiditis or other related conditions, sagittal views of the MRI seem to indicate hypertrophy of the ligamentum flavum, as well as the attendant spinous structures and processes at the L-5/S1 level. From what I can readily see, there is significant encroachment on the cauda equina at this level that doesn’t appear to be related to metallic instrumentation. The majority of operative “trauma” at this level, from numerous surgeries and fusions, has likely resulted in arthrosis and degeneration that would be expected. Given that 70% of my severe pain is located in the lumbar and sacral region, I’m somewhat surprised neither surgeon focused on this area as the culprit. Instead, both seemed scope-locked on the levels above, especially those mentioned on the radiologist’s report (L2-3). In the exact words of surgeon #2, “Look, this is all I do all day, every day. I look at MRI images. And I’m good at it. And I’m telling you, I see nothing that the radiologist claimed to see.”
I appreciate this surgeon’s confidence in his abilities, and I also fully appreciate his extensive training and expertise (which he reiterated 14 times during the visit). Yet, while he did have the images up on the screen for me to see, he never diverted away from the sagittal views. He was adamant that, “Axial views are much less reliable, and most radiologists rely too much on them when looking for stenosis.” He never focused on the hypertrophy of other spinous elements, nor did he offer to really take a close look at the area below L-4.
His diagnosis of Failed Back Syndrome was, I think, made in light of an absence of something else to tell me at that point. He rushed through my images, and while “this is what he does all day”, I think he likely missed the forest in the presence of the trees. I’m sure he sees a fair share of “surgery seekers”, “pill seekers”, and “doctor shoppers”, all of whom tend to challenge his opinions and assessments. I’m neither of those; instead, I’m a patient whose quality of life is diminishing, and whose career may be cut short due to a degenerative condition. I can appreciate, and accept, that yet a 6th lumbar surgery is futile and wouldn’t help. But if stenosis or arachnoiditis, or even cauda equina syndrome do exist, I’ll be a little more than angry that no one took an extra 10 minutes to look for it, and find it.
Neurostimulators have been discussed. I’ve conducted extensive research (both corporate and academic) into these devices, as well as the morphine pumps, taking into consideration my job and hobbies. It seems the morphine pump is more conducive to my needs, and would allow for operation during my biggest enjoyment, which is riding my Harley-Davidson. Stimulators are not to be activated while driving, riding a motorcycle, or operating machinery. I have a consult tomorrow, in fact, to discuss the pros and cons of each. Plus, morphine pumps decrease the physio-psychological side effects of oral opioids, so teaching in a more lucid state would be welcomed as well.
ONE QUESTION: With arachnoiditis, is bowel or bladder dysfunction a necessary symptom? I don’t have either, nor do I have tingling, pins/needles, or parasthesias in the legs. Only a throbbing pain… I do, however, have the sudden sensation of a taser gun or cattle prod hitting me in the area of the upper buttocks and hips, as well as the midline lower back.
I’ll refer to your site for sending images… Much appreciated, again.S.W., NC
#6842 In reply to: Lumbar Foraminal Stenosis: Discrepancy in MRI Impressions |Your care at this point has been less than generous. At the very least, one or both of the surgeons should have gone over your MRI images with you in detail and discuss salient points on the images.
From your report, no one has performed flexion/extension X-rays of your lower back. These are indispensable for understanding stability or instability. Even an AP (front to back) standing X-ray can yield valuable clues to the origin of your pain.
There are disorders that cannot be surgically treated (arachnoiditis and chronic radiculopathy- see website) but no one has mentioned those to you. Has anyone mentioned a spinal cord stimulator if either of these diagnoses could be present as a form of treatment?
I would be happy to review your films. See if your family doctor or radiologist would consider taking X-rays (AP, lateral, flexion and extension- all standing) to be included in your packet. Please call the office for delivery instructions.
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.Dr. Corenman,
HX: I am a white female, late 40’s, 5’6, 170, college professor, with standing diagnosis of DDJD since onset at age 18. I’ve undergone 21 orthopedic surgeries, 9 of which were performed on my cervical and lumbar spine. Procedures have ranged from discectomies, to laminectomies, to multi-level fusions. Latest surgical procedures included a posterior fusion at C2-T2 w/ dynamic stabilization instrumentation and BMP, as well as a posterior fusion at L3-S1 w/ dynamic stabilization instrumentation and BMP. Both fusions were conducted in 2008.
Total Spine surgeries: 5 Lumbar and 4 Cervical
Given my extensive surgical history, I’ve navigated acute episodes of pain fairly well. For the past 3 years, I’ve been under the care of a PM anesthesiologist, and my current pain management program primarily involves the use of opioids and other pharmaceutical modalities to control pain. Pharmaceutical management is preferred at this juncture given the failure of other conservative modalities such as ultrasound, therapeutic massage, intrathecal injections, PT, and so on.
During the past 12 months, I have experienced worsening pain in the lumbar spine, with a rapid onset of severe pain and other symptoms in the past 6 months. These symptoms include severe, debilitating pain originating midline around L-2, radiating bilaterally across the lower back, then down both thighs laterally and anteriorly. The pain then “wraps” around the thighs and migrates downward to the lateral calf area. In the past 3 weeks, the pain has migrated further into the ankles. This is the worst pain I’ve experienced since my first ruptured disk at age 18, which I can only describe as violent, stabbing, throbbing, and intensely spasmodic. I am awakened at night by a “jolt” of these sensations, and find myself unable to turn over, sit up, or stand. In the mornings, I need assistance getting out of bed, and ambulating without help takes almost an hour. My pain levels in the mornings are a 10+, and never reach below a 7 or 8 during the day. I am unable to stand completely upright, and have needed the use of a cane to walk. Standing and walking become intolerable after 10 minutes.
Current Distribution and Proportion of Pain: 70% isolated lumbar & sacral, 30% in legs.
While acute in nature, relief is sometimes achieved by forward flexion while standing (shopping cart position), or lying in a fetal position with knees drawn to my chest. This is difficult, however, due to the extensive instrumentation in my low back. I’ve researched these symptoms extensively, referring largely to peer-reviewed medical and orthopedic journals. Having had experienced similar symptoms, either central canal or foraminal stenosis seemed a likely suspect.
Recently, I made an appt with my attending orthopedic surgeon because I’m miserable. Upon hearing and observing my symptoms, he ordered an MRI with contrast to verify or rule out nerve root compression. The radiologist’s impression, aside from the usual degenerative changes / instrumentation at post-operative levels, read: “There is mild disk bulge and diffusion at the L2-3 level, more prominently to the patient’s right than left, with no central cord compression. There is moderate foraminal stenosis to the left, with moderate to severe foraminal stenosis to the right.”
My surgeon declined further surgery, indicating his “lack of confidence in his skill set” to enter my lumbar spine for a 6th time. The perplexing part of this is that he admitted only reading the radiologiy REPORT… My surgeon never looked at the images themselves. I have no idea why. He then ordered a transforaminal injection, and offered to send me to yet a 2nd surgeon for reassessment. I accepted, and was scheduled accordingly. The 2nd surgeon walked in the exam room, and bluntly asked why I was there. When I told him what my attending surgeon said, he informed me that upon viewing my MRI, “there was absolutely NO evidence of stenosis anywhere”, and that he was “very disappointed that a surgeon would order a transforaminal injection without viewing images, and only reading the written impressions of a radiologist.” Lastly, he (loudly) declared that this “so-called foraminal stenosis” was actually the titanium instrumentation mistakenly identified by the radiologist.
After enduring 10 more minutes of this surgeon’s unhappiness with life itself, I was informed that I had “Failed Back Syndrome”, and that my options amounted to lifelong pharmaceuticals, an implanted morphine pump, and/or retirement on disability. As I mentioned previously, I am a university professor, and my classroom obligations entail hours of standing. I’ve been forced to take medical leave this semester, given that my current pain level is uncontolled. My PM anesthesiologist is completely flustered at the degree of inconsistency between surgeon #1, radiologist, and surgeon #2. Thankfully, and until you can (hopefully) help, my PM doctor is having the radiology department re-read my films.
My purpose in writing you is twofold: First, I would be grateful if you’d offer to assess my August 1 MRI to determine whether lateral foraminal stenosis is, indeed, present, or if there is any other problem associated with the spinal processes and structures from L1 to S1. Second, is it possible that a radiologist could see “severe” anomalies, while another physician sees absolutely nothing? That’s a HUGE discrepancy, yet the 2nd surgeon noted no stenosis or decrease in fat levels around the nerve roots in question. I’m beyond frustrated, and could use a somewhat definitive evaluation of my symptoms versus objective imaging.
I’m sorry this post is so lengthy, but I wanted to provide you with as much HX and relevant symptoms as possible.
S.W. in NC
#6838 In reply to: c2-3 facet |Hello Dr Corenman
Sorry for the length. My symptoms are diffuse (c2-3 – t1-2), from a variety of trauma. There is both facet and nerve pain. Left side neck pain is the dominant, diffuse symptom, especially above the base of the neck, but downward and in the arm as well. There is no cord involvement or symptoms I am aware of. The traumatized c2-3 facet is a particular nightmare. The mri is normal, the area tender, with trigger points and what feels like some atrophy. You have suggested the inflammation or a severely degenerated facet may affect the nerve.Originally (1 year ago) I went to a Beckers list/Castle Connally (like our Vail, Colorado hero) pain management doctor. After receiving a thorough examination and questioning by the physicians assistant (who might have been too young to vote), she took the mri report and left to present the case to the doctor. The doctor soon arrived, coffee container in hand, only visible from the waist up as he leaned in the doorway. (He was not going to do any doctoring…today). His recommendation was to medial branch block the entire side. I was somewhat taken aback as they advertise the meticulous search for the pain generator. I asked how he would know which nerves to radiofrequency if the block successfully produced pain relief. He responded, “I burn ’em all, they’re all involved” and vanished. He was including c1-2 and possibly even c0-1 (not sure).
I went elsewhere to a pm doc with identical credentials who did the procedure in-office, sparing surgical center, anesthesiologist and even procedure expense (just co-pay) . The radiofrequency was c3-t1. A couple of months later I forced him to do c2-3. All results were minimal.
The odd part is this doctor started with only c3-4 (the opposite of the burn ‘em all doc). The short acting, 30 minute block weirdly produced 3 days of wonderful relief. Encouraged he next did a 4 hour marcane block adding c4-5 to the c3-4. No relief at all. Zero! Zilch! This morphed into the c3-t1 radiofrequency. Months later I convinced him to do c2-3. He first did a marcane block and there was 4 hours of great relief. Again the radiofrequency results were minimal. (there was an epidural in the middle which did little for pain but did reduce irritation, burning, tingling type symptoms for a couple of months. You have replied about out of position nerves, anesthetic spread vs needle width and capsule tear (although these were medial branch)
I am going to try pm again and am seriously contemplating the burn ‘em all doc this time for simplicity sake and his credentials.
Questions:
1-Do you approve of any radiofrequency at c1-2 (headaches are not a symptom)????2-Because this facet is surely enflamed, would it make sense for the block to be into the facet with anesthetic and cortisone vs medial branch (at least once). The injury and symptoms are years old????
3-In my case c2-3 and c4-5 must be done together this time and I would approve adding c4-5. Is there any downside to including all the way to t-1 as he seems to routinely do????
4-The common denominator to the relief I got twice on blocks seems to be c-3. Again the mri at c2-3 is normal but the facet is bad news. There are posterior discs (mild) with lateral extension also producing left foraminal stenosis at c3-4 and (c4-5) termed moderate but look and feel worse than that to me. C5 nerve root was +1 fib ans psw on nerve test -no weakness-but certainly sensory symptoms. Any idea why these blocks are so successful????
Thank you for everything Dr Corenman ( I read the forum daily and frequently re-read parts)
#6836 In reply to: Scared and Confused |I cannot understand the disregard displayed to you. No surgeon has 100% success and the patients that are having difficulty post-operatively are much more time intensive to help than the ones that have perfect results. If the results are not perfect, there is generally a reason for this. The work-up for less than perfect results can be difficult but needs to be completed.
Find a spine surgeon who would accept you for post-operative care. There are reasons for all your symptoms. You just need a work-up to find out why.
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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