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#33035 In reply to: Bizarre leg pain after 360 fusion |
My surgeon did order an MRI and below is the report. I continue to have almost constant LBP worse with sitting/lying/walking and it goes into buttocks and sometimes lower in leg. Particularly interested in what this means: “ There is also fairly strong postcontrast enhancement and high precontrast T2-weighted signal intensity around the disc space implant at L5-S1“
Report
Exam: MRI Lumbar Spine wo then w Contrast Date: 9/22/2020 8:35 AM
History: 38 years old patient with M54.5 Low back pain; Technologist reports: Low back pain with left leg pain x 3 weeks. History of surgery August 25. 2020. No injury.
COMPARISON: Lumbar spine July 23, 2020.
TECHNIQUE: Standard sagittal and axial sequences were performed before and after contrast including fat-saturated postcontrast
sagittal T1-weighted images. The patient received 15 ml of IV MultiHance. Exam is technically limited by susceptibility artifact
from metallic hardware in the lumbosacral area..
FINDINGS: There appears to be typical lumbosacral anatomy with five lumbar-type vertebrae, assuming T12 is the lowest rib-bearing vertebra. There are new metal artifacts from posterior spinal fusion
at L5-S1 as well as a disc space implant at the L5-S1 level, also
new. There is a small posterior midline incisional fluid collection
at the level of the L4 spinous process down to the L5 spinous process but not atypical given the short interval following surgery (fourweeks ago).There is no remarkable curvature on coronal images. There is been no change in alignment on sagittal images.
There is also fairly strong postcontrast enhancement and high precontrast T2-weighted signal intensity around the disc space implant at L5-S1 (sagittal series 9, image 4 through 11). However, there are no reactive marrow changes subjacent to the endplates and no suggestion of erosive or subsidence changes in the endplates. There is no apparent change in the other disks with only very mild disc space narrowing at L4-5 and relative disc dehydration at L4-5 and L3-4.
Vertebral body heights are well-maintained at all levels. Bone marrow is generally normal with no concerning bone marrow replacement or marrow edema at any level.
The conus and intradural lumbar nerve roots have a generally normal appearance. Specifically, there does not appear to be any contrast enhancement of the nerve roots or adherence between nerve roots or between the nerve roots and the meninges to suggest adhesive arachnoiditis. Conus termination is at L1-2, which is normal. There
is no evidence for epidural abscess, hematoma, or mass. On axial images:
At T11-12, there is mild bilateral facet hypertrophy with no disc abnormality or stenosis.
At T12-L1, there is no significant degenerative change or stenosis.
At L1-2, there are no significant degenerative changes and no significant stenosis.
At L2-3, there are no significant degenerative changes and no significant stenosis.
At L3-4, there is no change in very small but broad central disc protrusion associated with an annular fissure at the posterior midline. There is still no central stenosis or nerve impingement.
At L4-5, there is no change in very small broad central disc protrusion, also associated with an annular fissure in the posterior midline which has not changed. There is no nerve impingement nor significant central stenosisAt L5-S1, there is fairly prominent right anterior epidural enhancing scar tissue which extends around the right S1 nerve sleeve and into the new right hemilaminectomy defect. Again, however, there is no epidural fluid collection. The right S1 nerve sleeve is not significantly displaced or effaced.
IMPRESSION:
1. Compared to MRI two months ago, patient has undergone anterior discectomy and fusion as well as posterior spinal fusion with
hardware at L5-S1. Right hemilaminectomy also appears to have been performed. There is an enhancing tissue around the disc space implant at L5-S1, but the finding is of uncertain significance given the
short interval following surgery (about one month). There are no convincing findings of postsurgical infection and there is no epidural fluid collection.
2. Otherwise stable findings of mild disc degenerative change and very small broad central disc protrusions at L3-4 and L4-5. No lumbar nerve impingement or significant spinal stenosis demonstrated.#33022 In reply to: 3 Weeks Post Microdiscectomy Pain |Hi Dr. Corenman was hoping I wouldn’t have to write you again but I had a mishap this past Saturday and wanted to get your thoughts on what I am feeling. First I want to give you a brief recap on my recovery. Today I am 4 months post op on my L4/L5 (left leg). Recovery had been going well up to this point. I basically had no back pain the entire recovery but some lingering nerve pain that had finally subsided two weeks ago. Past two weeks I felt pretty close to 100%. I am very well read in the teachings of Professor Stuart McGill and have a solid understanding of spine biomechanics and know how to move in all aspects without putting my spine in flexation or extension. Since the 6 week mark I have been rehabbing with one of Stuart McGills practitioners so my weekly rehab program has been very calculated. My current rehab has me doing roughly 1 hour of core work a day and 30 minutes of walking so my capacity is fairly well built at this point.
Fast forward to Saturday. I went on a nature trail hike my with girlfriend and ended up standing on top of a fallen tree that was about 2ft from the ground. I tried walking across the tree but quickly lost my balance and landed straight up on my feet but the compression from the landing did a number on my back. The impact caused a feeling in my back I hadn’t felt before and within a few minutes the area around my shin became hot and numb. It was not sciatica per se, just heat and numbness. I was able to finish the walk and do my rehab for that day but my back felt off. Sunday I didn’t really have back pain but did have more heat and numbness around my shin.
Monday was my big scare as when I woke up I felt sore on both sides of my hips. Other than the first few weeks after surgery, I had yet to wake up in the morning with any back pain. The pain was fairy equal on both sides of my hips even though surgery was on my left side. This morning I woke up with less numbness and heat in my shin and it lasted about 2 minutes. Currently the pain around my hips is gone but my spine just feels compressed and tight right now, although overall I do feel better this morning than I did yesterday but did take an Advil before bed. I can still walk, sit, stand no problem but I obviously don’t feel as good as I did before Saturday.
Scientifically what do you think is going on? Did I likely compress my disc and it is just irritated or could this be a possible reherniation? I thought the annulus scars over after 8 weeks or so I would hope that a straight fall compression wouldn’t be enough to reherniate.
#33020 In reply to: L5-S1 Symptoms vs MRI |Your MRI notes a right disc herniation affecting the right S1 nerve root. Your symptoms don’t reflect the right S1 nerve but do indicate the left L5 nerve. Failure to raise your toes is an L5, not an S1 nerve disorder. You do have an S1 reflex deficit on the left (“Achilles (S1): normal on the right and absent on the left”) but that sometimes does not indicate a significant problem. The motor weakness is a pure L5 root deficit (“Ankle dorsiflexion (L4): 5/5 on the right and 4/5 on the left…Great toe extension (L5): 5/5 on the right and 3/5 on the left”
What is significant from the MRI report is “There is also foraminal stenosis on the LEFT” at the L5-S1 level which will compress the left L5 nerve root. Typically, the worst symptoms of foraminal stenosis come from standing and walking and improve with sitting and bending forward. However, when symptoms have been present for some time, sitting can be problematic. See https://neckandback.com/conditions/foraminal-collapse-lumbar-spine/
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.#33019Topic: L5-S1 Symptoms vs MRI in forum BACK PAIN |Good evening,
I have pain from my butt area down, and my left foot is numb. When raising my toes, my right foot is fine, but my left toes barely raise up. I notice while going on eliptical that I am using much more right foot/leg strength. Other issues I have noticed are lots of leg cramps in the back of my leg, and my toes are more curled on my left side. All of my issues are on my left. The MRI mentions right side. Does this make sense?Notes from last GP visit neuro exam performed on lower:
Manual Strength Testing:
Hip flexion (L2): 5/5 on the right and 5/5 on the left
Knee extension (L3): 5/5 on the right and 4/5 on the left
Ankle dorsiflexion (L4): 5/5 on the right and 4/5 on the left
Great toe extension (L5): 5/5 on the right and 3/5 on the left
Plantar flexion (S1): 5/5 on the right and 5/5 on the left
Sensory Testing (light touch) dermatomal patterns:
Medial thigh (L2): normal on the right and normal on the left
Medial knee (L3): normal on the right and normal on the left
Medial malleolus (L4): normal on the right and diminished on the left
1st web space dorsal foot (L5): normal on the right and diminished on the left
Lateral malleolus (S1): normal on the right and normal on the left
Reflex Testing:
Patella (L4): normal on the right and normal on the left
Achilles (S1): normal on the right and absent on the left
Ankle Clonus: absent on the right and absent on the left
Plantar response (Babinski): toes downgoing on the right and toes downgoing on the leftMRI:
L5-S1: Disc space narrowing with desiccation of the disc with central and RIGHTparacentral disc protrusion encroaching upon the RIGHT side of the thecal sac
and S1 nerve root. There are mild degenerative changes of the posterior facets.
There is also foraminal stenosis on the LEFT.
#32995Topic: Can nerve displacement lead to permanent damage? in forum BACK PAIN |Dr. C,
MRI 10 weeks post-op, after re-herniation, states, “At L5-S1 again seen is a right subarticular disc protrusion resulting in severe right subarticular zone stenosis, not substantially changed from before. Again seen is displacement right traversing S1 nerve roots.”
Symptoms are not debilitating as they were right before surgery, but they all too familiar. The shooting pain in gluteal, hips, hamstring, calf, etc. This is how it all began in February.
*IF* I do nothing and leave the S1 nerve displaced and constantly subjected to daily irritation — not severe irritation I assume since symptoms are mild — could nerve damage become permanent?
I feel as though my improvement has plateaued. Calf weakness has improved but not improving past 75% of the good leg. Radicular pain has subsided in intensity but still occurs daily.
Could ‘waiting it out’ actually do more damage versus going back in for revision?
Ty!
Frankie#32969Topic: neck pain/new mri in forum NECK PAIN |Dr. Corenman,
I am a dentist who had a microdiscectomy in December i recovered well. I was an ultra marathon runner and after the herniation i stopped running. I got into distance swimming(swims over 2 miles). I was really enjoying them and in May started to develop scapular pain and crepitation around the scapula with movement of my shoulder. The pain persisted, no decrease in strength some “strange” sensations of the forearm and lesser fingers but overall able to work without difficulty. I had an MRI four months ago and this is the report
C2-C3: No evidence of significant disc disease, spinal canal
stenosis or significant neural foraminal narrowing.C3-C4: No evidence of significant disc disease, spinal canal
stenosis or significant neural foraminal narrowing. The right
foramen is mildly narrowed due to small uncinate osteophytes.C4-C5: Right posterior T2 hyperintense annular fissure with a
small associated right paracentral disc protrusion measuring
approximately 0.7 cm craniocaudal, 0.3 cm AP and 0.9 cm
transverse, contacting and mildly flattening the ventral cord,
with mild canal narrowing. The dorsal CSF space is preserved. No
cord edema or other intramedullary cord signal abnormality is
seen. No significant neural foraminal narrowing.C5-C6: No evidence of significant disc disease, spinal canal
stenosis or significant neural foraminal narrowing. Minimal
posterior annular fullness, without canal compromise. Incidental
small elongated left perineural cyst.C6-C7: No evidence of significant disc disease, spinal canal
stenosis or significant neural foraminal narrowing.C7-T1: No evidence of significant disc disease, spinal canal
stenosis or significant neural foraminal narrowing.The left vertebral artery flow-void is diffusely smaller than the
right, most often reflective of normal congenital anatomic
variation. The right vertebral artery is dominant. The
visualized portion of the posterior fossa demonstrates no
cerebellar tonsillar ectopia. Paraspinous muscle bulk is
preserved.three weeks ago i had an injection of the C5 nerve root. This did not do much for my pain. My PT says this will improve yet the pain in the shoulders is constant. Is not a ten but a 3-5 but has not subsided. I am taking celebrex 200mg QD. I wanted to get your thoughts and see what your next steps would be. Should i just keep doing PT and another injection or should i see my Otho Spine Doc. THanks for all you do.
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