Donald Corenman, MD, DC

You report a large disc herniation at the left L5-S1 level. You unfortunately developed severe incapacitating pain in your leg associated with motor weakness. I’m glad you received chiropractic care that gave you relief but it would have been better to have seen a surgeon early. Two of the indications for a microdiscectomy are severe incapacitating pain and motor weakness and you did fit both qualifications.

If you had a disc herniation at L5-S1 with weakness, I assume you have weakness of the left calf muscles (gastrocnemius/ soleus group) and cannot tip toe while walking on that side. You report numbness and paresthesias (pins and needles feeling) in your left leg but no back or leg pain.

Based upon what you have told me, it appears that you need a microsurgery to remove the compressive disc from the S1 nerve. The fact there is no true pain is not necessarily a good sign as that portion of the nerve may not be transmitting due to possible compression and damage of the nerve root.

The surgeon advised a laminectomy and discectomy. I would assume that he meant a microdiscetomy which involves a very small laminotomy. If he wanted to do a laminectomy, that might have been overkill but I have not seen the MRI yet.

Surgeries proposed by different surgeons vary. I have seen fusions proposed for patients that have only needed decompressions, so I do not assume anything anymore. If you have a massive herniated disc that fills the canal and it cannot be removed without severe danger to your nerve roots, there is a very rare occasion that a full laminectomy can be necessary. I can tell you that I have never found it necessary to remove a herniation by that method but I can conceive of a situation where that might be necessary.

I would assume this surgeon means a laminotomy and microdiscectomy or discectomy (surgical procedure performed with loupes- not a microscope). It is the simplest of all spine procedures that I perform. If he is talented and meticulous as I assume many surgeons are, this procedure should go well without complications.

Dr. Corenman

A new MRI is only warranted if you have had a significant change of symptomatology and not just relief of symptoms. If you had more intense pain or different pain, a new MRI is necessary.

Some spine surgeons have different algorithms for treatment but most will perform surgery sooner than later if weakness is present.

An epidural in the presence of weakness I feel is not the best idea because it will reduce the symptoms of pain and paresthesias (tingling) but will do nothing to reduce the pressure on the nerve root. The patient (and ordering physician) will feel there is substantial improvement because the annoying symptoms have been reduced and will be lulled into thinking there is less compression on the nerve root which is not accurate.

There are times that an extruded disc herniation (a herniation that is fully ejected from the disc space and is an unattached free fragment in the canal) will migrate out of the canal in a short period of time. The operating surgeon will find the tear in the disc and some small fragments but the main offending herniation is not to be found.

I have seen on some occasions that the fragment is missed in surgery as it might be “tucked away” in a hidden corner and doesn’t reveal itself easily. These patients will have continued pain and weakness after surgery and have to be differentiated from chronic radiculopathy patients (see website for that condition).

The post-operative treatment varies from surgeon to surgeon. Your surgeon uses a back brace. I use a soft corset like those seen on Home Depot employees for six weeks. A recurrent disc herniation can occur in the immediate post-operative period and the position of BLT needs to be avoided (bending and lifting while twisting). The corset reminds the patient not to BLT.

I take care of many flight attendants and six weeks is not unreasonable to return to work if you have a strong core and good body mechanics. There is considerable overhead work with your job which magnifies bad body mechanics. The key here will be the physical therapist as this individual will be working closely with you for this period. I would depend upon the therapist to tell me if there are any remaining mechanical faults or weakness that would put your return to work in jeopardy. Of course, you need an experienced spine therapist to make that judgement.

The lump in your back is most likely from a seroma that developed or inflamed muscle and fascia and should soon recede. If it is painful to lie back with sitting, you can use a small wash cloth, fold it over and cut out a center hole slightly bigger than the protrusion. Tape this over the area. This will reduce the pressure while sitting. You could also tape this to your corset and wear the corset while you work for another 4 weeks.

Re-rupture of L4-5 is called a recurrent disc herniation and the chances are 10% in an active population.

Hope this helps.

Dr. Corenman

I can understand how you feel. It is difficult to watch your loved one incapacitated. As you can probably tell from this forum, my speciality is diagnosis. I cannot promise any cure but more likely than not an appropriate diagnosis can be formulated. Even if this turns out to be arachnoiditis, there are treatments that can manage but not cure this disorder. If you so choose, please call the office at 970 476-1100 and ask for Diana or Sarah.

Dr. Corenman