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in reply to: Back pain after microdiscectomy #24467
Hi again Dr Corenman
So I went to see my new surgeon today. We chatted through the options. We discussed 2, first, neurolysis and second, putting in screws with a pair of semi flexible cords at the back to reduce mobility and support the spine. He does not like fusion much.
Looking at the last scan he is still pointing at something that could be a disc fragment alongside the nerve and that is slightly distorting the shape of the swollen nerve. He is not certain though and this would contradict what the radiologist who did the MRI thinks (i.e. nothing but scar tissue). He also sees the disc tethered just as it exits the foramen.
I asked if the neurolysis could be done without cutting me open. The study I mentioned in my last post actually talks about going in with a catheter guided by fluoroscopy and feeding tools in using that. He says that would not be appropriate as its much too deep and close to the spinal cord, so he would go in laparoscopically, like the original microdiscectomy. I was concerned about additional scar tissue build up. He said that it was a risk but I would be unlikely to end up worse than I am now, given he is looking to open up the space again and maybe shave off some neighbouring bone to make more space. Bottom line he thinks this option has a 60% chance of success.
We discussed the pedicle screw option. He is confident about this and says he has used it with athletes etc successfully. He said that this solution would have the benefit of preventing the hypermobilty that the shrunken disc is allowing and would therefore protect the nerve because the nerve would not be moving around so much plus the disc would be under less pressure and less prone to any bulging into the nerve, but I would of course lose about 50% mobility in the joint. He thinks this option has 85-90% chance of success, just with the bigger side effects and longer recovery time,
On balance my wife and I decided that the less invasive option was the better option for now. I can always go back and have the screws in later if it does not work. We agreed that We would know if that was required 3 months post op.
So now I am booked in to have the neurolysis on the 6th April.
Right now my pain is only minor as I am doing everything possible to avoid annoying the nerve. So I don’t sit or drive much, I do little stretching or mobilisation of the nerve, I swim 750m every day which I can tolerate ok now, even working reasonably hard. I sometimes think it is overkill to have surgery again but then I have nothing like a normal life right now. I have just got used to it I guess! As my wife said, not being able to sit comfortably really limits life a lot. That is where I am now.
Does all this seem sensible? It’s a while until my surgery so I have a while to reconsider…
I would really appreciate your thoughts, especially if you think there are risks that I have not considered.Many thanks as always
Michaelin reply to: Back pain after microdiscectomy #24441Hi again Dr Corenman
Since my last post things have remained more or less static. I saw my old, trusted GP and he tried oral steroids again to see what would happen. 80mg down to 20mg Prendnisone over 16 days. It had some effect lessening the intensity of the nerve pain, but it has gone back to the status quo ante again now. He told me to arrange another appointment with his favoured surgeon (the one I saw a couple of times late last year). This is booked for next week.
It seems like I still have something that is irritating the nerve and I am supposing it’s scar tissue. I am also thinking that aside from tethering, the physical presence of the tissue is causing an issue. I often get some of the worst pain when I am just lying in bed (on my back or side) or else when in a reclining chair, so not when I am really stretching or moving anything. Oddly and fortunately, somehow it is less when I sleep so I don’t tend to wake up from the pain. I have a reasonable amount of flexibility (i.e. At a push I can reach out and touch my toes both sides) but I don’t push that too much.
The pain in my spine has come off quite a bit I am pleased to say. I swim 15 mins 650m every day at present and am incrementing that about 50m every 5-7 days. A few months back that would have really hurt my spine and left a band of pain either side of my l5 but that doesn’t happen now. Walking downhill for a while can be a problem so I figure that is mechanical shock absorber issues due to the lack of disc tissue.
So my issue remains this nerve pain. It varies a lot from day to day. Sometimes it’s in the calf. Sometimes I have burning feeling in my heel. Sometimes I have pointed aching in my thigh or glute. On bad days it is high up near the disc but off to one side, so basically anywhere along the S1 dermatome. Usually a combination of a few of these on any given day. The intensity varies quite a bit as well and without any reason that I can figure out, which is a bit grim. I can have a couple of good days and then wake up one day and it is just inexplicably worse again, and I have to be careful all day and spend much of the time bed.
So, I wonder if you can give me advice for when I see the surgeon next week? Should I be asking about neurolysis to free up the nerve? I read a paper from NICE in the UK that had about 50% of people getting benefits from what they referred to as adhesiolysis.
https://www.nice.org.uk/guidance/ipg333/evidence/overview-314283853Otherwise is there anything else that you could suggest or recommend?
Many thanks again for your time and help. It is much appreciated.
Michaelin reply to: Back pain after microdiscectomy #24110Hi again Dr Corenman
I hope you are very well. Thanks again for your response. As always, read with interest.
Re the ESI treatments, I understood from some articles on the web that there is a variant of the ESI that also introduces an enzyme to break down scar tissue. I think it’s Hyaluronidase. I gather this is referred to as lysis of adhesions or Adhesiolysis. I found a couple of studies in the nih.gov site that seem to suggest that it can result in better outcomes than PT alone. E.g.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3903797/
Is this something you would consider in a case where the presence of scar tissue is causing ongoing pain?In my case, I think that I have maybe kept the nerve moving as my flexibility is not too bad, but aside from sitting which is always trouble after a while, even lying down and other positions where I have pressure on my lower back cause pain after a while (I have developed a habit of lying in positions that raise my left side up slightly to compensate), so I am thinking that there is just too much tissue around the nerve and it is keeping the nerve under pressure all the time. Standing for short periods or walking relieve the pain as I guess they are not mechanically causing the pressure on the area. Anyway, that’s a bit of a digression. Sorry.
I will be speaking to the radiologist who has done my 3 ESIs next week. Is it worth me asking about lysis using enzymes and steroids or is it just not an accepted treatment among serious and professional practitioners?
Thanks again for your assistance. It’s really much appreciated.
Michaelin reply to: Back pain after microdiscectomy #24077Hi Dr Corenman
Many thanks for getting back to me. Since my last email my surgeon has reported back on the recent MRI with a call before Christmas He is now minded to agree with the radiologist and says that if there was something on the August MRI here does not think it’s there now. It may have been reabsorbed. So just scar tissue remaining.Also, I had another ESI, this time more diagnostic into the SI joint (28/12/16) Actually it did seem to work a bit. I think i have had some reduction in pain overall and pain at the top of the SI joint specifically seems to be a noticeably less. Tricky to say when pain seems to come and go in various forms and places but I think that is the case.
My nerve symptoms have been a little better the last few days as well. Less ache and shooting pain in my leg which is very welcome. Definitely not gone, but certainly better than say, a month ago. I am still having to be careful and sitting for more than 20-30 minutes causes the pain to start up again and I have take care doing stretches etc as getting that wrong can cause pain that lasts a day or so.
If anything, I am finding as I am trying to be more ‘normal’ with less pain in the leg and along the nerve then I am getting more axial pain, actually in the spine itself. When it comes, its a sharper more steady pain rather than the slightly less focussed and zappy nerve pain. It comes on especially after I try swimming or lots of standing around so I am thinking it’s actually pain from the disc after sheering or compression. Not much I can do about that I guess, except building the core muscles for support. Everyone seems to recommend swimming. I do it with minimal twisting if I can, but it does seem to irritate something actually in the spine. Again this is less than when I tried swimming a couple of months ago, but still in two minds. Do I carry on in moderation in an effort to rehab the back overall or is the residual pain telling me ‘no, not yet’?
Re the nerve pain, you mentioned neurolysis. It sounds like you were talking about a surgical procedure in the case of your pro skier. On that topic, is there anything in RACZ neurolysis? It looks like a glorified ESI with added enzymes to break down scarring so I guess should not risk re-scarring that surgery might cause. Have you seen evidence that the RACZ prodedure is safe and effective?
Thanks again.
Michael
PS I am certainly not averse to a paid consult btw. I will keep that in mind.in reply to: Back pain after microdiscectomy #23531Hi again Dr Coreman
I went for my next meeting with the surgeon last Wednesday. He said words to the effect of “look you have symptoms that suggest something is pressing on the nerve. The last MRI may not show anything clearly but they don’t always capture everything that’s actually in there”. I was sceptical as the last thing I want to is plough ahead with unnecessary surgery and make things worse. After some umming and arring we agreed I would have another MRI and schedule one last ESI in my IS joint in case that was inflamed.
I had the MRI on Monday. I got the CD and took it home to look at it. I could immediately see that a structure that the surgeon had pointed to as a potential problem (a black line sitting right next to the nerve) was even more clear and was also clear in the contrast image so could not be scar tissue. I thought ‘that’s it! That’s the junk that has been irritating the nerve all along’. I got myself mentally ready for surgery and was really glad that there was something to explain my symptoms that could be removed.
The next day the radiologist called again about the new MRI. He said 100% the object I saw is NOT disc material. He said it was most likely a blood vessel and that there is no disc material impinging on the nerve.
So I am back to where I was. I would really love to believe the new surgeon. He is a professor of neurosurgery with years of experience. His narrative says that a minor surgery will fix me. But the images and all other doctors (4 so far) that have seen them say no reherniation or problem material in there except scar tissue. No one else has suggested revision surgery.
My next appointment with the surgeon is 20th January… My last ESI is 28th December.
Apologies, I know thee is no question here. I just wanted to keep the thread up to date.
Merry Christmas :)Ps if you are interested in seeing the images I would be happy to share them. Just let me know how I can do so. I dont have the radiologist’s report but even if I did it would all be German as I am in Switzerland, so not sure that would be useful, even with help from Google Translate!
in reply to: Back pain after microdiscectomy #23521Hi Dr Corenman
I have been mulling things over and have read another thread here that explained a few things about scarring (your thread with Bird, really informative).
Only one of 4 doctors that have looked at my August MRI see any reherniation. The radiologist last week was pretty adamant that there was none. So I was thinking.I am pretty flexible in my leg now. I can touch my toes with no pain (which is encouraging). However sitting and standing still are still bad. Plus I found that if I lie flat on a bed or in a reclining chair then the ache sets in (back and leg) very quickly but if I can tilt my pelvis up on the bad side then I can get away with it.
Looking at the MRI there is a clear swathe of scar tissue on the outside and just above the S1 nerve root. So I am thinking that maybe, while I have managed to keep the nerve untethered from the scar, the presence of the scar tissue is still compressing the nerve at the top and outside.
My reasoning as to why my why scar tissue became an issue overnight (as opposed to over a few weeks) after overactivity (when all this started) is that the movement and strain caused the nerve to swell up a lot and the motion of the joint disrupted existing scar tissue so it thickened up and maybe shifted into a worse position.
Then as to why things are better than they were (although far from fixed) is because the nerve has become less inflamed over time and maybe the scar tissue has consolidated a bit.
So… does that sound consistent to you? I read in the other thread that scar tissue does shrink over time as a natural process. Did I understand that right? I sure hope I did as if my understanding is right then I guess that is my best shot for recovery given surgery to remove scar tissue is a big no-no.
I have a tricky chat coming up with my surgeon on Wednesday I reckon…
As ever thanks so much for your help. -
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