Archives

It appears that you suffered a disc herniation at L4-5 when doing back extensions so many years ago. The L5 root was compressed and you developed radiculopathy. You don’t mention any foot weakness (the L5 nerve could cause foot drop, weakness of ankle inverters and a trendelenberg gait)- see web site for these conditions.

Normally with a disc herniation, the symptoms will slowly decrease over time. The tear in the back wall of the disc however does not heal. Since the process of degeneration does not stop, the nucleus (inside jelly) can disrupt and become another free fragment. A recurrent (repeat) disc herniation occurs in about 10% of patients. This is what probably happened after the bowling incident.

The comment by the neurosurgeon about one vertebra slipping on the other sounds like a spondylolysthesis. There are two types that might affect you- isthmic and degenerative. These should be obvious on x-ray and MRI. Look at the radiology report to confirm this slip.

If you have back pain and leg pain- what is the percentage of back vs. leg? This makes a difference as back pain is generally caused by the spinal column itself (instability, degenerative disc disease or spondylolysthesis) and leg pain which includes buttocks pain is caused by nerve compression.

The fact that sitting causes more pain is somewhat encouraging as this may indicate that the disc herniation is causing much of the pain. However, the percentage of back vs. leg pain will help to understand the correct diagnosis. Please feel free to send your films into the office.

Dr. Corenman

From the interpretation of your e-mail, you were initially diagnosed with the pars fractures when you were 15 years old and you are now 20 years of age. You don’t mention if you have a slip of L5 on S1 (isthmic spondylolysthesis) or fractures without slip (isthmic spondylolysis).

Treatment is now a somewhat controversial area for this disorder as we have developed very good ways to repair the fractured pars. However, repair surgery is not recommended if the disc has become degenerative or there is a substantial slip of the vertebra. In addition, repair does not absolutely guarantee full pain relief.

Let us assume that you have degenerative changes as many individuals do with long standing pars fractures. What normally happens to cause pain is that after the fracture is initially discovered (when you were 15), the fractures remain but the pain disappears. After an incident such as lifting or twisting, the pars pannus (see web site for this) tears or the disc itself tears.

The treatment, in my opinion is first to reduce the stress on the vertebral segments. Collagen fibers (that make up the torn pars pannus) take about 3 weeks to heal and 3 more weeks to develop tensile strength. Rest is good for a short while. Using a soft corset is also helpful. Isometric strengthening exercises for the core muscles is helpful initially. Eventually, the therapist will have to introduce loading and rotational exercises and hopefully, by 8-12 weeks, the repair has occurred and the pain has receded. I don’t mean that the fracture heals- that won’t happen, but the pars pannus can heal. Some individuals heal somewhat faster and some might continue with some discomfort.

Hope this helps.

Dr. Corenman

I assume the nerve root compression is at the same level as the original compression. It is very good that you have no neck pain as your options are expanded. The symptoms that radiate into your thumb and index finger most likely indicate the C6 root (at C5-6). If you had a herniation at that level before, you probably have a combination of herniation and spur now.

Cervical surgery has four indications; Myelopathy (compression of the spinal cord), weakness of important motor groups (a C6 nerve would go to the biceps and wrist extensors), instability and pain that is not tolerable. Surgery for weakness is more of a value judgment but recovery of motor strength after surgery is not guaranteed. It is therefore probably better to not wait if weakness is a major factor.

Pain is the major surgical variable. If pain, numbness and paresthesias (pins and needles) are the only complaints, a program of physical therapy and nerve injections (SNRB- see web site)can be effective to control and manage the symptoms.

If the symptoms are intolerable, then surgery is warranted. Your choices are an ACDF (decompression and fusion) or an artificial disc. There are benefits and drawbacks with each (again- see website for descriptions of these).

Hope this helps.

Dr. Corenman

By your description, it sound like you had a bilateral decompression of the L5-S1 level. The description of the cyst removal at left S1 leads me to believe that you have degenerative facets at that level. Cysts can occur from other structures but 95% of cysts are ganglion cysts and are associated with degenerative facets. To carry the association further, degenerative facets are associated with degenerative spondylolysthesis (see that topic discussed in the web site under “conditions”).

There are four possibilities that could have occurred to cause continued pain. One is that simply the nerves are still inflamed from surgery and over time, they will calm down and the pain will go away. The second is that there is a hematoma (a collection of blood) that is causing compression and again, over a period of time, it will resorb and the pain will recede. The third is that there could be a recurrent ganglion or herniation and that may need to be diagnosed.

The forth possibility is foraminal stenosis or lateral recess stenosis that may be part of the initial pathology. If your pain occurs with standing and walking and disappears with sitting or bending forward, the last possibility is more likely. Check the section on foraminal stenosis to see if that might fit with some symptoms.

The x-rays may give some clue. The x-rays need to be taken in the standing position and hopefully, x-rays were also taken in the bending forward and backward positions (flexion and extension). If there is a slip of L5 on S1, this would mean a degenerative spondylolysthesis is present. Decompression surgery (which is the surgery you underwent) can occasionally aggravate this condition but understand that decompression surgery by itself is generally indicated and OK for this condition.

Let me know what you find out.

Dr. Corenman