nakurac

Dr. Corenman,

Thank you for actively supporting this forum. I have learned a ton reading peoples questions and specifically your answers.

I am a 36 year old healthy male, 6’3”, 210lbs. I had my 1st L5-S1 micro-d in 5/2012 and 2nd (due to moderate reherniation) on 5/2013, both to take pressure off the right S1 nerve root. Both surgeries alleviated the right-leg nerve pain along the S1 greatly; however within 2 weeks of the 2nd surgery, I believe I have reherniated for the 3rd time, except this time it’s into the right formanial area where the L5 nerve root is sitting based on the leg symptoms I describe below.

CURRENT SYMPTOMS
The back pain is present 100% of the time and varies in intensity depending on the activity. It is located just to the left and to the right of the lumbar midline and wraps around both hips, all the way to the top of the iliac crest. If I am not moving (i.e. just standing or sitting), the back pain is 0 VAS. If I had a moderate workout the back pain can be as high as 8 VAS where I cannot even bent slightly at the waist. In addition, I have constant bilateral buttock pain which also varies in intensity. At all times, flexion hurts more than extension. I do not have any instability as presented on the recent flexion/extension standing x-rays. I take no medication.
My right leg pain in along the right L5 nerve dermatome (pain on the outside of my calf, top of my foot, and big toe). I can dial it at depending on my torso positioning or movement. If I am stending up straight and lean to my right while standing (as in closing the foraminal gap) the pain jumps to 8 VAS and my right forefoot and big toe starts tingling. As soon as I back off the pressure on the nerve (torso back in neutral), the pain goes to 1-2 VAS. It’s like an on/off switch. Activity and stretching improve the overall leg pain. It almost diminishes after Yoga for example for few hours and the on/off switch is more difficult to reproduce.

RECENT MRI READING
At L4-L5, there is a symmetrical disc bulge with focal left foraminal protrusion which flattens the ventral thecal sac and moderately narrows the left neuroforamen and impinges the left L4 nerve root.
At L5-S1, postsurgical changes of right L5 and S1 laminectomies and again noted which decompresses the central canal. There is broad-based disc bulge with right-sided inferiorly oriented disc extrusion by approximately 4 mm. This results in severe narrowing of the right lateral recess. Additionally, there is enhancement in the right foraminal zone and in the soft tissues of the laminectomy sites, likely secondary to the granulation tissue, slightly decreased compared to prior MRI. This results in severe narrowing of the bilateral neuroforamina with impingement of the right L5 exiting nerve and a second right S1 nerve root. There is also an impingement of the left L5 exiting nerve.

RECENT DISCOGRAM READING
L4-L5: 3 mL of contrast was injected with soft endpoint. The patient did not pain during the procedure. Contrast extends diffusely throughout the disc indicative of the generalized degenerative disc pattern. Schmorl’s node formation is noted in the superior and inferior endplates. There is contrast noted diffusely throughout the disc and extending into the Schmorl’s nodes. There is minimal generalized bulging of the disc without contrast extension through the posterior annulus. The facets are normal. There is no significant narrowing of the central canal. There is minimal narrowing of the neural foramina bilaterally secondary to the generalized disc bulging.
L5-S1: 3mL of contrast was injected with a moderate endpoint. The patient reports 6/10 discordant pain in the back. The contrast pattern demonstrates diffuse degenerative disc change. There is contrast noted diffusely throughout the disc indicative of generalized degenerative disc disease. There is also generalized bulging of the disc as well as cephald extension of contrast presumably within the area of the disc extrusion into the right foraminal region abutting the exiting L5 nerve root. There is also cortical extrusion of contrast presumably in the area of extruded disc in the posterior central location just touching the anterior aspect of the thecal sac.
The facets are normal.

The interesting thing about the discogram is while I was laying there feeling the pressure, the pain was 6/10 as it states above and it was discordant. However, within 20 minutes of me getting up, I felt the same concordant pain. It was delayed by 20 minutes. The next two days, the same concordant pain persisted, just like after a major activity like a long hike or a game of basketball. Any explanation to this?

Painwise, I can do all things I need to do. I cannot do many of the things I’d like to do in my current state. The back pain is more debilitating, but the right leg pain is more bothersome. Does it make sense to proceed with the one-level lumbar fusion and why? I am extremely nervous and cautions about jumping into a salvage procedure. How do I build an objective case of pros vs. cons? In my mind few things do not form a clear case:
1. Discordant pain
2. Two previous micro-d procedures (I am thinking scar tissue)
3. No relief after 2 epidural injections around the L5 nerve root
4. Normal Sensory / EMG study

How straight-forward is my case based on my symptoms vs. films and chance of improvement with fusion?

Any comments on the meaning of the reports above would be appreciated. Your staff said that you are not doing video consultations any longer.

Thank you for your response and keeping this forum active. I am very well familiar with the lumbar spine anatomy, fully understand my post micro-d CT scan and MRI reports, and doctors’ logic behind further treatment options.

I may have other surgical options for nerve pain, but I am only interested in fusion. I was reaching out to you for general fusion questions, not necessarily best treatment specific to my condition. I know exactly how on the paper the successful fusion will help. I know how it will “lift” the L5-S1 neural foramina to take roof-pressure off the nerve, decompress the axial nerve (if required), and stabilize the joint to relieve the axial back pain.

I have seen few doctors, but am struggling going forward w/fusion due to the inconsistencies on fundamentals which I think are important. My specific perspective surgeons disagree on the relevance of maintaining lumbar lordosis, need for direct vs. indirect foraminal nerve root decompression, relevance of neural foramina opening size etc. Also another dilemma, 1 or 2 levels.

Of course, some of this goes along with their fusion techniques (i.e. TLIF vs ALIF for direct vs. indirect nerve decompression, PLF vs. interbody for relevance of foraminal opening size). All surgeons have compelling arguments on why their plan of action and technique is the best my specific case.

Even published technical papers don’t agree on the “best technique” for the same clinical picture and patient symptoms scenario. I understand that the “tools” of the job can be different but don’t understand how fundaments can be different for something this important – an irreversible procedure.

Can you comment on this? My two failed micro-d surgeries left me very paranoid. In addition, the internet is filled with very bad fusion outcomes.

I had a repeat microdiscectomy in late May to remove material pressing on the s1 nerve. Surgery went without complications, but 2 weeks after a moderate sharp leg pain returned. 4 weeks after surgery date (two days ago), the pain became severe and in locations other than where a dermatatome map shows for s1 pathology. Yesterday’s MRI report indicates a severe right foraminal stenosis secondary to the granulation tissue at l5-s1.

I am worried about this finding and feel hopeless. Looks like I traded one problem for another much more painful and serious. What should I do? Could this be the temporary result due to tissue inflammation? I am still awaiting my surgeons advice.