Archives

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

Cervical stenosis that causes cord compression produces spinal cord dysfunction and the symptoms of myelopathy. The spinal cord is not just “a long nerve” but in reality an extension of the lower part of the brain. Damage to the cord is similar to damage to the brain. This is why decompression of the cord is important prior to the onset of significant myelopathy. Surgery is designed to prevent further damage and recovery from cord injury will not be known for a year.

The cord has functions that involve coordination of the muscles. Your sister recovered her walking ability which is wonderful but she was left with residuals of hand incoordination. Full recovery is not guaranteed. Hard work and relearning through tracts that are undamaged is important. There is no way to know what the final outcome will be.

Dr. Corenman

Think of the healing of the pars fracture like the healing of a broken leg. You don’t want to go running on a broken leg until it heals and if you did run on it when it was still broken, you would impede healing. The same with this pars fracture. The mechanism of fracture is with extension, so extension is avoided until healing. The reason the bone fractured in the first place is the amount of extension generated with your serve and overhead shots.

Hopefully, the fracture heals with a great amount of callus formation. Callus is like the excess metal from a weld on a steel tube. It can create greater strength than the original bone had. However, a “partially healed” fracture may not have the same strength as the original fractured bone and possibly make you vulnerable to another fracture.

The bone scan is a radioactive tracer attached to a protein that accumulates in reactive bone. The scan will show up “bright” in areas of greater bone activity. It is a good test to see if there is a possibility of bone healing as if the area does not “light up”, the chances of healing are greatly diminished. The bone scan does not reveal if the area is healed- only if it has the potential to heal.

Physical therapy is one of the cornerstones of recovery after the bone is healed. If you return to your previous activity patterns in tennis however, physical therapy may not help you avoid refracture.

The bone stimulator probably does not help much, but even a little help is better than nothing as this stimulator has no down side that I am aware of.

Dr. Corenman

If the pars is reported to be “partially healed”, that definition depends upon the interpretation of the radiologist. A pars fracture can heal without a full joining of 100% of the bone ends. If the other side of the vertebra is not fractured and the fracture side has 50% of the fracture ends fully united, more likely than not it will withstand extension. Extension occurs with your serve and overhead.

The reason the bone fractured in the first place is the significant forces to the pars generated with these actions. It is a possibility that the fracture can occur again. If the fracture occurs again, you might need a surgical pars repair.

Dr. Corenman

A unilateral pars fracture of L5 is very common in tennis players and professional skiers. The serve and overhead both cause significant extension (bending backwards) of the spine and this can overload the bone causing this stress fracture. Make sure this fracture is not a facet fracture (a lower fracture in the same bone) as the facet fracture has a different prognosis.

If this is truly a unilateral pars fracture, there is a good chance it will heal but healing will take at least three months. This means no tennis or any exercise that would put your back into extension. Think of this fracture as an ankle fracture. I don’t think you would run, play tennis or lift weights with an ankle fracture- so treat it as that.

Bracing is optional but I like to use braces for this fracture as it reminds you not to bend backwards which destroys the healing potential. This fracture may not heal in spite of your carefully reduced activity. Without healing, the other side that is intact will react to the increased stress. It may go one of two ways. It may develop more bone to compensate for the increased stress (hypertrophy) which is a good development or it may eventually fracture from the overloaded stress.

If the other side does hypertrophy, the pain most likely be reduced but may not completely go away under load. Healing potential can be ascertained with a bone scan but the MRI can also give similar information without a radioactive tracer being used. I always obtain a new limited CT scan (just the fracture area and not the entire lumbar spine) in athletes to look for healing. The fracture is repairable surgically if necessary.

Hope this helps.

The pain from a disc tear or herniation can develop in the neck or the arm or both. You may have a very sensitive nerve root and a small herniation can cause pain in the arm. Did you have flexion- extension x-rays? These can reveal instability that the MRI won’t. Did you receive an epidural or selective nerve root block and if so, did you keep a pain diary for the first three hours after the injections? If you are not sure- please see the sections on epidural/ selective nerve root blocks and the pain diary on the web site. By the sounds of it, you would not benefit from electrodiagnostic tests (EMG/NCV) so if those are suggested, the tests will probably not show anything. It sounds like you need a new set of eyes to look at you and render a diagnosis. Don’t be frustrated as it may take more than one doctor to give you an appropriate diagnosis.

Dr. Corenman