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Lying prone on the floor (on your belly) causes extension of the back (backwards bending). Leg numbness in that position fits with the diagnosis of foraminal stenosis.

Again, to diagnose foraminal stenosis, AP, lateral, flexion/ extension standing x-rays, an MRI (with gadolinium if surgery was within a year period). If foraminal stenosis is identified, a SNRB (see website) with good relief will indicate that foraminal stenosis is present.

The three procedures that relieve formaninal stenosis are a foraminotomy, ALIF or a TLIF, depending upon the amount of collapse and how many prior surgeries have been performed.

Consult your surgeon to see what he thinks.

Dr. Corenman

According to your history, you had a laminotomy/ microdiscectomy at left L5-S1 14 years previously most likely for a herniated disc. You then re-herniated the same disc presumably on the same side 3 months ago. This is not uncommon as the recurrent herniation rate is about 10% in an active population.

You underwent a redo microdiscetomy at L5-S1 left and had no improvement after surgery and even developed symptoms in the opposite leg. A new MRI reportedly demonstrated no further nerve compression but inflammation only.

Some questions. Did you have any relief in the intensity of the left leg pain after surgery or did the pain change in quality or location? Does the pain increase when you sit and bend to tie your shoes or does it improve with those positions? Does the pain become worse with standing and walking or does it improve? Is the pain constant and does not change with any position and does it have a burning quality?

The reasons for those questions is that there are three potential sources of pain. One is that the pain source might have been not fully diagnosed. If you have foraminal stenosis (see website), you will have pain with standing that improves with sitting (the opposite of herniated disc nerve pain). The MRI will reveal foraminal stenosis if closely observed. This can be diagnosed with a selective nerve root block.

If there is a residual fragment of disc material that is still compressing the nerve, the MRI may also reveal it. Ask to review the MRI report from the radiologist. This report may be complicated, but it still can be interpreted.

Finally, you may have chronic radiculopathy. If the nerve has been injured by these recurrent herniations, after surgical decompression, the nerve needs time to heal. This occurs 90% of the time and heals by Mother Nature. Full healing is not always guaranteed and residual pain can continue. It may take 6 months to know if the nerve will heal. Epidural steroid injections are a good treatment as nerve inflammation is significantly reduced with these. Membrane stabilizers like Neurontin are also beneficial medications if there are minimal side effects.

Dr. Corenman

By your description, you have herniations at C5-6 and C6-7 on the left with C6-7 being a larger herniation. These herniations would compress the C6 nerve (C5-6 herniation) and the C7 nerve (C6-7 herniation). Symptoms of a C7 herniation would be shoulder pain that radiates into the middle of the hand, weakness of the triceps, MCP extensors (straightening of bent fingers) and wrist flexion (bending the wrist down). C6 compression symptoms would be shoulder pain radiating into the thumb side of the hand, weakness of the biceps and wrist extension (bending the wrist up and important for grip strength). Neck may or may not be present- it depends upon the tear of the disc itself.

You have already had a very good conservative treatment program with chiropractic, physical therapy, traction and epidural injections.

There are new complaints of paresthesias (pins and needles) down the arm which concern you. Paresthesias are generated from the proprioception portion of the nervous system. This is the system that tells your subconscious brain where your body parts are in space.

Symptoms of paresthesias generally are an indication of nerve root compression and new onset symptoms are slightly concerning. The most concerning symptoms to me however are the generalized weaknesses of the muscles of the arm. This requires some explanation.

There are four nervous system functions carried by one nerve root. These are sensory (compression would cause numbness), noceceptive (compression causes pain), proprioception (compression causes paresthesias) and motor (compression causes weakness). All except the motor are pure sensation type transmitters. The sensory roots can cause these symptoms with only mild compression but the motor portion of the nerve root is much tougher and more compression is required to make it dysfunction.

When weakness develops from motor nerve compression, this means the compression is significant. The motor nerve root does not recover easily after compression and some patients even after decompressive surgery may not recover full motor strength. The nerves that are the most to least sensitive are T1, C8, C5, C7 then C6.

There are four indications for neck surgery, significant motor weakness, spinal cord compression, instability of the vertebra and intolerable pain. You have at least one of the indications.

In my experience, PRP will do nothing for symptoms of nerve compression. Epidural steroid injections are the single most effective treatment for pain but will do nothing for motor weakness. PT is very important for function but will not help motor weakness.

My opinion is that surgery for motor weakness is the best option. In the face of a disc herniation without neck pain, surgical options include ACDF or artificial disc (see website for discussions). Motor weakness with neck pain most likely requires ACDF only. There are no studies regarding how quickly the surgery needs to be performed but in my opinion, the quicker the nerve is decompressed, the better the chance of recovery.

Hope this helps.

Dr. Corenman

By your symptoms of right back, buttocks and leg pain that becomes worse with prolonged standing and an “instability pain” in your back (a popping noise with debilitating pain), you could have several specific problems. More likely, you have lateral recess or foraminal stenosis (see web site for description). You may even have facet dysfunction or a degenerative spondylolysthesis. Standing x-rays including flexion and extension x-rays and an MRI may help diagnose the pathology.

Thoracic pain can sometime be difficult to diagnose but again, x-rays and an MRI can be quite helpful.

Inability to raise your right arm could be from a rotator cuff tear (do web search for this), an injury of the C5 nerve (originates from the C4-5 level in the neck) or from arthritis of the shoulder joint. A good examination can reveal the origin of this problem along with x-rays and of course an MRI.

Most fractures leave a bone deformity that can be seen on x-ray or occasionally a CT scan.

I can’t promise anything but I would be happy to look at your images for you.

If you wouldn’t mind- I would like to have your permission to make your letter anonymous so that I can put it in the forum as the forum is designed for patient education and every little piece makes a good teaching point.

Thank you

Dr. Corenman

Standard X-ray series for lower back pain varies from doctor to doctor. The very basic X-ray series is an AP and lateral lower back image. This will give basic data on disc, alignment and degenerative changes. If the series is performed in a standing position, so much the better as now there is evidence of gravity’s affects the spine.

I include a standing flexion and extension lateral x-ray for a 4 view series as instability can be determined by these additional X-rays and cannot by any other means.

The scoliogram X-rays (full spine front and back view) are normally reserved for patients with deformity by examination (scoliosis, increased kyphosis, old fractures). In the States, it is not common for those images to be included unless suspicion of deformity or imbalance is suspected.

I do not use oblique films much anymore as these are designed to look at the pars of the vertebra and rarely yield much new data.

Dr. Corenman