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Hi Dr. Corenman,
Firstly, thank you so much for this forum and your website. The world is lucky to have people like you who are willing to spend their time and share their expertise with others.
I’m hoping to get your feedback on microdiscectomy surgery. I have a large L4-5 disk herniation and have had varying degrees of sciatic pain since August 2019.
On October 1st 2019, around the time my symptoms began to worsen, I had a lumbar spine MRI. The exact wording on the report is:
“Large right para-central disk herniation compressing the proximal right L5 nerve root against the adjacent facet and causing posterior displacement of the right-sided nerve roots. The epidural canal is capacious. The conus is anatomic. Neural foamina are patent throughout. There is no spinal or lateral recess stenosis.”
As stated above, my sciatic pain over the last 6 months has ranged from severe (I went to the emergency room after a coughing fit in January 2020, couldn’t sleep for more than an hour or 2 at a time in October and November) to moderate (I am now walking about 40 minutes at a brisk pace, albeit with a slight limp and am able to sleep an average of about 4 hours at a time).
My back does not hurt. All of my pain is in my right leg, mostly my right buttock and sometimes in my calf and thigh. For about a month now I have had pins and needles in my right foot when sitting or walking too long and I have lost some sensation in the big toe on my right foot. My reflexes are normal and an EMG that I had done in December 2019 showed no significant nerve damage. I can now raise my leg to about 45 degrees during a straight leg test in the seated position (I was at 5 degrees at the end of October). I can sit on a chair for up to 20 minutes. Although there are many times when I can’t manage for more than 5.
One aspect of my condition that has not improved one iota since October is lying down. I can’t do it at all, not even for 5 minutes. The minute I lie down in bed I feel a sharp pain in my right buttock. The pain increases in intensity the longer I stay laying down and it eventually becomes unbearable. And so, for the last 5 months, I’ve been sleeping on a recliner.
I have been told that I am a candidate for a microdiscectomy but I am reluctant to proceed with the surgery as my pain, for the most part, is moderate. However, I am deeply troubled by the fact that I cannot lay down in a bed to sleep.
I’m an otherwise healthy and active 35 y/o female and desperately want to get back to my life pre-herniation. What are your thoughts on having surgery in the absence of severe leg pain when standing/walking/sitting but excruciating pain when laying down?
Thank you,
AndreaPeek spacers have a lower solid fusion rate so a pseudoarthrosis (lack of fusion) is a possibility. If you then added the energy of a motor vehicle accident to your neck, this could have increased the pain. You will probably need a CT scan to look at your fusion levels.
Facet arthroplasty is a less than effective way to either make facets work after degenerative wear or cause a posterior fusion depending upon the device. The flexion/extensions would reveal if these devices are sliding surfaces or fusion devices.
Before a steroid injection is used, imaging would be much more helpful to determine your status.
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.#32008Topic: Extrusion at L5S1 Level in forum BACK PAIN |Hi Dr
I have a history of bulge at L4-5 level 10 years earlier and I got fit by physiotherapy. Now in October 2019 I got another incident of Protrusion ant L4-5 and S1 level, I uderwent for physiotherapy but no relief. Moreover I was getting worse, so I went for another MRI on January 15, the report findings are as under:
Screening images of the whole spine reveal loss of cervical lordosis. Degenerative spondylotic changes are seen in the cervical spine with marginal end plate osteophytes and degenerated intervertebral discs displaying hypointense signal on T2-weighted images. Diffuse disc bulges lead to thecal sac indentation from C4-5 to C6-7, more so at C5-6. The spinal cord is normal in bulk and signal intensity.
OPINION: MR scan findings are suggestive of :-
· Broad-based posterior disc protrusion at L5-S1 with right-sided propensity with a right paracentral disc extrusion, compromising the lateral canals, right > left and right intervertebral foramen with right asymmetrical traversing nerve root impingement.
· Diffuse symmetrical bulge at L4-5, along with thickened ligamentum flavum, compromising the left intervertebral foramen without nerve root impingement.
As compared to the previous MRI dated 31.10.2019, there is fresh right paracentral disc extrusion at L5-S1 that was not seen on the previous scan. The rest of the findings are unchanged. Please correlate clinically.
Now I am taking Methylprednisolone 32 mg daily. Please suggest what is the right action for me.I have heard and read about you a lot and I believe I am at right place to get the answer of my problem.
#31982 In reply to: Worsening symptoms 6 weeks post lumbar microdiscectomy. |The MRI findings are pre surgery, yes.
The surgeon didn’t really go ober the operation much with me. He just approached me in the recovery area and told.me there was a tremendous amount of pressure on the nerbe and I should have been in there sooner.
It leads me to believe it was a unilateral procedure.How would you compare your current symptoms to your preop symptoms in location, intensity, activity restrictions. How much change has occurred and how have your symptoms evolved after surgery?
Worse. Much more pronounced post surgery.
preop, I barely ever felt discomfort in my feet, it was mostly in the glute and leg.
Intensity, maybe a 6/10. I could stand for maybe about 10 minutes before starting to “dance around” on one leg. Its pretty much the same, now.How the symptoms evolved over time:
The first 2 weeks were fine, but I did feel tingling in my left foot toes that was not present preop. Right after the first 14 days, the morning of my follow up appt with my surgeon actually, I began to feel mild familiar “soreness” radiating down the left leg.
I informed my surgeon, we did a straight leg test and he was pleased. he told me to take Aleve once every 12 hours and double the dosage
week 3: Took double dosage NSAIDS for 1 week and aside from making my blood incredibly thin, it did nothing to aleviate the symptoms. I felt tingling in the left side of my body and face and my personal doctor was very alarmed by this. He instructed me to cease the double dosaging.
week 4: Feeling better! More stable. Not wearing back brace so mUch, doing some walking around the house.
week 5: woke up late at night, was very thirsty so I grabbed a bottle of water out of the refridgerator, bent low to do it and felt a bit of a “pop” in the lower back but that was nothing really out of the ordinary and wasn’t painful. Immediately went back to sleep.
Woke up with symptoms. 7/10, I can walk around, I can live life but I can feel it, too. Its been like that for a week.The only real improvement is preop, getting out of bed, it felt like the bottom side of my left foot was burning or tearing, as I got out of bed. That is not the case, now. Also my posture is better, in the morning I would walk sort of hunched over and I dont have to do that, now.
#31978 In reply to: Worsening symptoms 6 weeks post lumbar microdiscectomy. |“My orthopedic surgeon is one of those “don’t want to know you” after surgery types. Can’t blame him”. I think that his behavior is inappropriate. He is your surgeon and should help you, not just be a technician.
You note “worsening radiculopathy in left glute/leg/foot 6 weeks post lumbar microdiscectomy…Original surgery: microdiscectomy: L4-L5”. How would you compare your current symptoms to your preop symptoms in location, intensity, activity restrictions. How much change has occurred and how have your symptoms evolved after surgery?
I will assume the MRI findings are presurgery; “L4-L5: 6mm broad-based disc extrusion contribute to several central canal stenosis and severely narrows both lateral recesses with mass effect on the cauda equina…L5-S1:..2-3mm right paracentral disc protrusion moderately narrows the left lateral recess and may contact the descending S1 nerve root”.
Based upon reading this (through an unknown radiologist’s eyes), the L5_s1 level could have been left alone as you had severe changes only at L4-5. Did you have a bilateral procedure or just unilateral?
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.I’m unclear what a “facet arthroplasty” at C3-4 is. Did you have some metal fusion implants (DTRAX) into your facets at C3-4 or some type of posterior surgical debridement procedure?
You had an ACDF fusion of C4-7. What was the graft used? Was it your own bone (autograft), donor bone (allograft) or a spacer with manufactured bone (PEEK and DBM)?
It is not uncommon to have a failure of fusion at one level be non-symptomatic for 4-6 months and then demonstrate symptoms. Also, the level above and below can develop symptoms. I wonder about C7-T1 as you have some symptoms (“numbness off and on ending at elbow with some tingling in baby and ring fingers”) that can be referable to that level. When you follow-up with your surgeon, at least flexion/extension X-rays should be considered if not a new CT scan to go along with the MRI.
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. -
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