CPG890

Dr. Corenmn,

I am writing again with some new information but mostly seeking help on how to think about what is going on and where to go from here. I am two months out from the Gill Laminectomy and Bi-Lateral Foraminotomy and I’m feeing way worse off then ever before. I’m having severe axial back pain centered right over the L5/S1 area and I’m getting broad sciatic pains across both of my hips, butt, down the back of my legs, behind both knees and into both calfs. The pain increases with sitting and after a long walk, the pain increases significantly. I’m to the point where I have started needing Percocet 5/325 at night just to be able to sleep and Tylenol 1000mg during the day just to get through the day. I continue to feel a pinching and grinding sensation what seems to be at L5. I often get these loud clunks in that area and also feel that “jiggling” instability sensation I was familiar with pre-op of my ALIF. Needless to say, I’m in bad shape and seem to be getting worse.

I have now seen four different surgeons trying to understand what is going on and get a firm diagnosis. One surgeon said my fusion is healed. The second surgeon (my surgeon) said, L4 is clearly healed and he’s inclined to think L5 is also— but, “with a very skeptical eye, it is at least very close to fully fused”. The third surgeon just kind of shrugged his shoulders and said he really didn’t know if all segments are fused and that it’s hard to tell but to wait as fusion can take up to two years with bone remodeling. The fourth surgeon said it was also hard to tell but anatomically things look good, give it more time (again, bone remodeling explanation) and that I should consider a spinal stimulator if any surgery was to be done in the future. I was shocked at that surgical recommendation. They all looked at the same CT Scan and the same MRI at 8 months out from the ALIF. (The CT and MRI were taken before the most recent laminectomy and foraminotomy operation).

Come this February will mark one year since my two-level ALIF. Should I get another CT-scan and MRI? Will those tests (particularly the CT Scan) be conclusive as to whether L5 is fused? If I get another CT Scan, this will mark my 4th CT-Scan of my abdominal region, which, concerns me given the radiation dosage. (1st scan was for kidney stones in 2012, the second was pre-op ALIF and the third was September last year…). If having another CT Scan will yield a definitive answer AND inform an intervention then I am more inclined to accept the risks of the test. If it’s just to check and isn’t really definitive, then I’m a little dubious to expose myself to the significant radiation again.
You mentioned selective nerve root blocks and sacroiliac joint blocks as a diagnostic procedure to rule-out the sacroiliac joint as a pain generator. I am assuming the selective nerve root blocks would be at L5 to test whether L5 is the pain generator. If I got the selective nerve root blocks at L5, how does this test the fusion? In other words, what information are we gaining from this? Are there any other tests (needle or imaging) that test fusion status? Perhaps, flexion/extension can be taken?

Looking back on my history, I feel like the pars- interarticularis injections diagnostic test proved to be a “false positive” leading me to believe that the remaining Gill fragments were causing my pain which led to the decompression operation. Now, all that bone and fibrous tissue is gone and yet I remain with the same instability pain sensation.

You said in your last response: “I will assume that with two surgeons viewing your CT scan that you do have a solid fusion as that is an avenue I would pursue if you came in to see me.” Are you saying that your feeling is that I am not fused at L5 and would test that hypothesis? Any chance this could continue to heal and fuse on it’s own at this point despite me feeling worse?

I frankly would love to come see you for an evaluation. I have no problem traveling from Atlanta. Or, at the very least, have a paid phone consultation, which you did offer. (I first would like to know if new imaging studies are necessary so I can send them to you). My only regret is that my insurance carrier is not listed on your webpage as in-network coverage nor do I have out of network coverage so if we conclude that surgery is needed, I regrettably wouldn’t be able to have you do it.
Thank you again.

-CPG

Dr. Corenman,

I am the original poster of this thread and I am getting back with an update and a question for you. It has been over six months (operation was Feb 1st) since my two-level stand-alone ALIF (L4-S1) with anterior plate at L5/S1 to fix the grade-one isthmic spondylolisthesis at L5/S1 and degenerative disk at L4. Put simply, things are not going well. I have continued back pain coming from, what I think is L5/S1, where I feel the pars defect rubbing and clicking. The L4 area does not hurt.

My surgeon is quite sure I did not fuse at L5/S1 but L4 is unclear. He wants a CT Scan to evaluate fusion and also an MRI (maybe with contrast to see neuroanatomy) and said that if I am not fused, a posterior gutter fusion with pedicle screws would be appropriate. He is hoping that L4 is indeed fused and that the posterior gutter fusion would just need to be performed on L5/S1 where the spondy/pars defect is. The positive is that I have no neurological deficits at this time. I do have considerable back pain which feels mechanical in nature and results in moderately/severe sciatica episodes if I do too much and irritate the nerve roots.

I am in the process of having these tests completed in the next few weeks. My question to you is: Do you offer paid phone consultations and/or second opinions to patients that are not local? This forum is wonderful and you have been so helpful thus far, but, I would like to have you evaluate my case specifically with all the necessary imaging studies and speak with you formally as to where I go from here.

Thanks again for your time,
CPG