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Please slow down to describe your history.

14 years ago you had your first laminectomy at L5-S1. You did well until March of this year when you lifted a keg of beer. You developed back, buttocks and left leg pain. You apparently had surgery again- I will assume another decompression laminectomy.

Your symptoms became worse and changed after surgery. By your description, the original symptoms intensified and new symptoms developed. Forgetting your neck symptoms at this point- did any new symptoms occur in your lower back, left leg or right leg? Do your back and leg symptoms become worse with standing or sitting? Do you have new pain in your right leg? What is the ratio of pain in your back to pain in your leg? Is your back pain worse than your leg pain in a 60/40 or 70/30 ratio or is it reversed?

The surgeon stated to you that there might be an infection present. Did he work that up to disprove it or could there still be an infection present?

The clumping of nerves in the spinal canal is from arachnoiditis. The surgeon identified arachnoiditis before your March 2011 surgery and thought that it was not causing problems. Does he now blame the arachnoiditis for your current symptoms?

You developed neck pain and arm paresthesias 3 weeks after your latest lower back surgery. Most likely your neck symptoms are from a problem in your neck and not related to your lower back. These symptoms could have developed from a preexisting problem that just surfaced, an aggravation of a problem from the intubation during surgery (preexisting foraminal stenosis that was aggravated by the extension maneuver necessary to intubate your trachea), or something else. There is an extremely rare possibility that if you did have an infection in your lower back disc, you could have seeded your neck with a new infection.

What does your surgeon propose as the next step?

Incapacitating lower back pain for 15-20 years with failure of conservative treatment means you could be a surgical candidate. It depends upon the results of the physical examination, the MRI and X-rays, possible further testing (discograms and/or SNRBs) and your expectations of surgical results.

Let’s just assume your discs above L5-S1 are pristine on MRI and your alignment of all discs but L5-S1 on X-ray including flexion/extension films is within normal limits. If your examination makes the diagnosis unclear or there is suspicion of a possible pain processing issue (abnormal brain processing of pain), you would need discograms (see website). If your diagnosis was crystal clear, you might not need further workup.

If everything was crystal clear on the diagnosis, most likely a TLIF of L5-S1 would have a 85-90% chance of reducing your lower back pain by 2/3rds. This means that if one hundred patients were operated on with your exact diagnosis, 85 to 90 individuals would agree that they have approximately 66% relief of the previous lower back pain.

Dr. Corenman

A new MRI is only warranted if you have had a significant change of symptomatology and not just relief of symptoms. If you had more intense pain or different pain, a new MRI is necessary.

Some spine surgeons have different algorithms for treatment but most will perform surgery sooner than later if weakness is present.

An epidural in the presence of weakness I feel is not the best idea because it will reduce the symptoms of pain and paresthesias (tingling) but will do nothing to reduce the pressure on the nerve root. The patient (and ordering physician) will feel there is substantial improvement because the annoying symptoms have been reduced and will be lulled into thinking there is less compression on the nerve root which is not accurate.

There are times that an extruded disc herniation (a herniation that is fully ejected from the disc space and is an unattached free fragment in the canal) will migrate out of the canal in a short period of time. The operating surgeon will find the tear in the disc and some small fragments but the main offending herniation is not to be found.

I have seen on some occasions that the fragment is missed in surgery as it might be “tucked away” in a hidden corner and doesn’t reveal itself easily. These patients will have continued pain and weakness after surgery and have to be differentiated from chronic radiculopathy patients (see website for that condition).

The post-operative treatment varies from surgeon to surgeon. Your surgeon uses a back brace. I use a soft corset like those seen on Home Depot employees for six weeks. A recurrent disc herniation can occur in the immediate post-operative period and the position of BLT needs to be avoided (bending and lifting while twisting). The corset reminds the patient not to BLT.

I take care of many flight attendants and six weeks is not unreasonable to return to work if you have a strong core and good body mechanics. There is considerable overhead work with your job which magnifies bad body mechanics. The key here will be the physical therapist as this individual will be working closely with you for this period. I would depend upon the therapist to tell me if there are any remaining mechanical faults or weakness that would put your return to work in jeopardy. Of course, you need an experienced spine therapist to make that judgement.

The lump in your back is most likely from a seroma that developed or inflamed muscle and fascia and should soon recede. If it is painful to lie back with sitting, you can use a small wash cloth, fold it over and cut out a center hole slightly bigger than the protrusion. Tape this over the area. This will reduce the pressure while sitting. You could also tape this to your corset and wear the corset while you work for another 4 weeks.

Re-rupture of L4-5 is called a recurrent disc herniation and the chances are 10% in an active population.

Hope this helps.

Dr. Corenman

Let us start from the beginning. The MRI is applicable only after we have an idea of the symptoms, then the history of how this started, what treatment you have had and any consultations and opinions. A physical examination is important to narrow the potential disorders and then the MRI is used along with standing X-rays including flexion and extension X-rays to determine what the disorder is.

Obviously, a physical examination can’t be performed over the internet (at least at this time) so we am limited to vignettes.

Let us start with symptoms. You state “I do have some leg and buttocks pain that shoots down my leg from time to time with severe fair ups”. Also “I try to stay active but walking, sitting and standing really make things worse so I walk with a cane to help with support”.

So you have buttocks and leg pain but no lower back pain. You do not note the side of leg pain. Buttocks and leg pain normally originate from the same source, compression of the nerve root. Walking and standing increase the pain. This is normally generated from foraminal or lateral recess stenosis (see web site). Use of a cane normally is necessary if there is motor weakness (you don’t state if you have weakness- only a reference from the injection physician) or from the need to bend forward while ambulating. Forward bending with walking is caused by a deformity of the lower or mid back (unlikely in your case) or antalgia (the need to assume a particular position because of pain- more likely in your case). Did you get any relief from the epidural injections?

So possibly we are looking for the cause of foraminal stenosis or lateral recess stenosis. You state the MRI notes the L5-S1 segment is not in alignment. The radiologist did not note this on the MRI but the lack of notation of that finding is not unusual. If there truly is a slip of L5 on S1, the cause most likely would be from degenerative spondylolisthesis or isthmic spondylolisthesis (see web site).

Degenerative spondylolisthesis is caused by significant wear of the facets where in isthmic spondylolisthesis, the facets are normally pristine as they are not loaded because of the old pars fracture. The MRI report states “”The L5-S1 level shows a bulging annulus and bilateral facet” “hypertrophy. There is increased bulging towards the left, causing impingement of the left S1 nerve root as was previously noted. Mild bilateral foraminal narrowing is present.”

Bilateral facet hypertrophy is a code word for significant facet arthritis or severe wear of the facets. This goes along with the diagnosis of degenerative spondylolisthesis and your observation of the slip at L5-S1 (you possibly picked it up when the radiologist missed it!) may complete the picture.

Putting it all together leads to a possible degenerative spondylolisthesis of L5-S1 with either foraminal or lateral recess stenosis compressing the L5 or S1 nerves (or both). Your nerve root is compressed with standing and walking forcing you to lean forward which requires a cane for ambulation. I assume you are in much less pain with sitting or lying down with your knees bent or standing and leaning over a counter.

If this is correct, there are many disorders that can be helped by acupuncture but this is not one of them. Depending upon the length of time you have had this and the treatments you have undergone, you might be a candidate for surgery. The surgery would depend upon the stability of the vertebra and that can be determined by both the MRI and standing X-rays including flexion and extension views.

If you would like, you can send me the MRI and X-rays and I would be happy to throw in my 2 cents. Call the office and ask for Diana or Sarah at 970 476-1100.

Dr. Corenman

My understanding of your history is that you have osteoporosis or osteopenia from years of use of a steroid inhaler, hypertension and had one year of lower back pain. That pain increased in the middle of February and by the middle of March, the lower back pain increased and you developed leg symptoms. This was from a herniated disc at L5-S1. You underwent a decompression surgery- most likely a microdiscectomy.

I don’t understand the sentence “After the surgery I was fine accept weakness of my right leg and burning at time of discharging urine and stool.” Did you have residual weakness of your leg or new onset of weakness after surgery? Discharging urine and stool- did you have bowel and bladder malfunction prior to surgery or new onset of these symptoms after surgery? Did you have burning on urination which could indicate a urinary tract infection?

You state you have continued symptoms in the right and left “back hip”. Is this area the buttocks, the sacroiliac joint or the back of the thighs? When does this pain become more severe?

Most microdiscectomies do not require further surgery but it is unclear what is currently causing pain. You need to have experienced eyes look at a new MRI of your spine and you need a detailed physical examination.

Dr. Corenman