MidwestW

MidwestW wrote:

Hi. I had only one decompression at L4/L5, which did not relieve the pain.

My TFESI was done at L4/L5

To be more clear: I’ve had two discectomies at right L5/S1, each time reherniating, so you are going to be fusing L5/S1 this month.

With my last discectomy, in March, I also had left L4/L5 decompressed, which gave partial, but not total relief of L5 radiculopathy. I did get full relief from a nerve block of L5 delivered at L4/L5 on the left. I can send those procedure notes to you if you’d like.

Donald Corenman, MD, DC wrote:

OK. Your right-sided symptoms are a result of your new herniation. Your left-sided symptoms are more likely from the continued lateral recess stenosis. Since you have had two prior decompressions on the right at L5-S1, you do now need a fusion of that level.

However, since you need a surgery of the level above (L4-5) on the left with a prior decompression already under your belt, this level should be considered to have a fusion (TLIF) also. You could choose to have an L5-S1 fusion and a redo 4-5 decompression only but with prior failed surgery at L4-5, a fusion would be a good choice or this level could break down again leading to a future fusion. I still think the TFESI mentioned earlier should be considered to connect the MRI findings with the symptoms.

Dr. Corenman

Dr. Corenman,
You and I spoke last week (I’m Wendy M.), and I’m scheduled with you later this month for a TLIF on L5/S1 due to the third-time reherniation there (copied our prior conversation above since it’s been a while). What we did not discuss on the phone is the left side.

The same time I had my last discectomy at L5/S1, I had a laminectomy at L4/L5 for lat. recess stenosis. While the right got better (until it reherniated), the left only got a little bit better, and I continue to have L5 radicular symptoms on that side. The new MRI, which you have, shows “residual compression of the L5 nerve due to facet hypertrophy,” and I even paid to have the MRI read by a board certified neuroradiologist, who found the same thing (I am copying his report below). Three weeks ago, I had a TFESI at left L5 and had immediate relief that then lasted two weeks. The anesthesiologist told me this confirmed that the compression at L5 in the lateral recess was to blame for the pain.

I actually have an appt to talk with you on Thursday, but thought this might be faster–I’m really concerned that the L5/S1 fusion will help with the right-sided pain, but that I, like you suggested earlier in the forum, also need a TLIF fusion on L4/L5 since I have remaining stenosis that requires a facectomy. I really want to fix all the nerve pain once and for all, and definitely want you to be the one to do it, so wanted to ask you about a TLIF at the L4/L5 level ASAP in case that changes scheduling. Here is the MRI report I got from the neuroradiologist out of New York (I sent the original report with my CD). I’m sorry if this is burdensome to you since we are already talking this week, but as I am in trip-planning mode I want to make sure that if this level is added on the schedule stays the same. Sara has all my info and I’ll talk to you on Thursday but wanted you to have the benefit of this info first. Thank you!

NEURORADIOLOGIST READING:
Narrative to patient: The left lateral recess is stenotic with compression of the nerve roots. There is an annular tear of the L4-5 disc; however, I suspect the root compression from left facet hypertrophy should explain the pain rather than chemical radiculitis. Facet hypertrophy contributes to foraminal effacement at L4-5 and L5-S1. The loss of disc height at L5-S1 may contribute to the development of the hypertrophy. There is stenosis of the left L4-5 lateral recess and direct left forminal effacement at L5-S1. Both of these may contribute to left L5 dermatome radiculopathy.

Report:
L4-5: There is loss of disc height and T2 weighted signal. Mild disc bulge with an annular tear is
noted. Facet hypertrophy contributes to left foraminal effacement and stenosis of the left lateral
recess. The left L5 root is compressed.
L5-S1: There is loss of disc height and T2 weighted signal. There is disc bulge with an annular
tear and a large right paramedian disc herniation with obliteration of the right lateral recess. Facet
hypertrophy yields left foraminal effacement.
Paraspinous structures are within normal limits.
IMPRESSION:
Post-operative changes with disc disease at the L3-4, L4-5, and L5-S1 levels.
Significant right l5-S1 disc herniation yields obliteration of the right L5-S1 lateral recess.
Facet disease contibutes to left L4-5 lateral recess stenosis and L5-S1 foraminal effacement.

Thanks. A couple things:

-I do have weakness on the right. It is not extreme, but I cannot hold myself up on my toe very long. My surgeon has still indicated he thinks that I should try injections first.

-On the left side, the MRI report notes some mild compression of the L5 nerve root, which corresponds to my symptoms on the left. But my surgeon says he doesn’t see that and thinks it is inflammation. Even if something is “mildly” compressing a nerve, can it cause pain? I definitely have pain there (no motor weakness, that is just on the right).