BillL

Dr. Corenman:
I am trying to hold off MRI another couple weeks until week 8 post op to be more to the looking of the original surgeon and maybe better accuracy….

I did speak with at least one local surgeon who does some far lateral access discectomies but for a second procedure Accessing from that position per his usual minimally invasive dilator method he was a bit cautious (even if a residual or recurrent herniation is confirmed on MRI). He suggested that at least with the minimalist approach that he would have to remove more bone laterally including some off the superior facet joint area. He seemed a bit concerned about how much bone was removed by the laminotomy and partial medial facetectomy. Suggestion was if not enough bone left only recourse would be a TLIF?

He also mentioned the symptoms of late mainly around the posterior right belt line, at times laterally about halfway between the iliac crest/femoral head, and occasionally just below the ASIS as maybe having hip or hip girdle Sx, yet hip exam normal. Sitting and rising from sitting after a while seems to somewhat briefly radiate a discomfort in one of those areas. My PT also started trying to track that direction due to this being “non-dermatomal” or maybe atypical. No problems walking or climbing stairs, etc.

I read one article that suggested there might be some paramedian approaches with a slightly longer incision (vs minimal dilator) that could completely spare bone removal laterally? I have concerns to avoid TLIF if at all possible and concerns about effects of violating the superior facet joint and it’s capsule…..? Instability? Arthritis? Facet pain? And not sure about this hip girdle concept as it seems the other doctor perhaps wanted to consider that before tracking to a revision surgery….

Any thoughts appreciated…

Okay, thanks. I will try to coax an MRI order hopefully in the next couple weeks or so.

One additional thing that he said after the post op visit that I thought a bit odd: he commented that he thought a possible NCV and EMG could be indicated and made a suggestion that he was a bit baffled how I could be still having significant pain/radiculitis in the face of a “normal neurological exam.” This was a bit strange to me since my neurological exam was normal and without sensory loss or significant motor weakness during the entire pre op period and continuing as such to this day. Maybe I am missing something but would think that in the absence of sensory or motor symptoms or exam deficits that the utility of such additional studies is questionable? And I would also surmise that perhaps my intermittent largely positional pain might not show EMG/NCV abnormalities? Possibility of attempting to use such tests (assuming normal) to validate an argument that nothing else is “significantly wrong”?
Do you see any virtue in these tests whenever the 6-8 week post op time frame arrives or at any point without sensory/motor symptoms or abnormal exam?
Thank you.

Dr Corenman:
Update: I saw the surgeon for the first post op visit today at about 4 weeks and 3 days. Symptoms continue. He was I little on the defensive side despite my symptom descriptions and questions being carefully and tactfully posed.

At any rate he says during the surgery that he accessed the subligamentous fragments successfully. He recalled encountering what was apparently an extended fragment inside the formaninal area, presumably with some extending inside the lateral foramen. He thinks he found the medial edge of the existing annular tear/fissure but placed a more medial additional cruciate annulotomy a short distance away presumably for better access. The. Used an angled curette of sorts to push the extruded fragments back through the original tear, then retrieved them from within the annulus via his annulotomy.

When I politely queries about more lateral elements he said he was confident that he “got it all” and that he probed all the way out through the foraminal passage with a very open and non obstructed nerve clearance. Even said that he wasn’t that impressed with the extraforaminal bulge and that many people with that don’t have direct or significant nerve root compression and are often asymptomatic.

He said regeneration was always possible but didn’t seem to add much credence for some reason. Still says continued nerve root inflammation can go on for many weeks and that up to 3 months would not usually bother him in absence of motor weakness or debilitating pain.

When I proved a bit more as to what IF there were residual or recurrent farther lateral issues, and potential approaches he seemed a bit annoyed. Basically said that he doesn’t like the lateral approaches although has done them in the past….said that in the extraforaminal location that the diesel sleeve is absent on the nerve root, and that the root and the annulus can appear almost identical causing high risk of nerve injury. This in addition to the statement that virtually breathing on the dorsal root ganglion can severely irritate that, causing even worse and prolonged pain.

Finally, after probing a possible repeat MRI he said he favors wating 3 months post op. When I suggested that was longer than my comfort he acted though he would consider by 8 weeks post op if symptoms persist. Yet he also was surprised that a recent trial of NSAIDs and a MDP had little effect.

At this juncture not sure what to make of this and which way to proceed. To further complicate issues, as you know, surgeons have this 90 day insurance “global” payment whereby must handle the post op issues for that time frame. Many local surgeons will not even see a patient post op until after these 90 days expire.

Any additional insights Would be appreciated and thanks for your help thus far.