radiculopathous

Dear Dr. Corenman,

I’ve stumbled upon some data about recovery rates, I thought
I’d share this with you here as it adds a bit of detail to a
prognosis for nerve damage recovery.

This paper has some quantitative data on the nerve recovery
process post microdiscectomy:

“Recovery of muscle strength after microdiscectomy for lumbar
disc herniation: a prospective cohort study with 1-year
follow-up” (Gregor Lonne et al., 2011)

(Sorry I can’t put the URL in here your web forum software
doesn’t allow it. Search it on Google, easy to find full PDF
text for free.)

Executive summary:

– 1 year out, 75% of patients recover fully; 15% partially, and
10% not at all.

– The only predictive factor found was the intensity of the
“paresis”, based on “Daniels and Worthingham’s” method (I’m a
grade 4, 50% weak (or le.

– Pre-op duration of paresis was NOT significant (though their
median was pretty low at 6 days, these Norwegians operate
quickly I presume, and they admit to a low sample size)

Selected quotes:

“This study shows that 75% of the patients with limb paresis
due to herniated lumbar disc had full recovery 12 months
after micro discectomy. Patients with mild paresis can be
informed that they have a good chance to recover (84%).
Patients with severe paresis have less, but still a good
chance to recover (55%). Fifteen percent had some improvement
but not complete remission, and 10% had no improvement. The
recovery rate was similar to the results published earlier
[2, 6, 19, 20]. Previous studies evaluating more severe
paresis (grade 3 or worse) show similar associations between
the severity of paresis and the recovery rate [5, 7, 21].”

[..]

“Only the severity of the paresis was identified as an
independent risk factor for non-recovery. Surprisingly, there
was no association between the preoperative duration of the
muscle weakness and recovery, and we could not identify any
cut-off in duration of paresis that would indicate a good or
poor prognosis for recovery. This is an important finding
which does not support the concept that the best effect of
surgery is obtained in patients with short duration of
paresis. The size of our sample might, however, have an
impact upon this finding. We did not look at patients with
paresis less than 24-h duration, since duration of paresis in
this study was difficult to define in terms of hours.”

Ha… comments which brings up a few more questions which I believe aren’t covered anywhere.

1. Regarding that recurrence figured… have you seen a correlation between the level of activity during the 6 weeks recovery period and reherniation? That’s probably difficult to assess objectively. I noticed you mention somewhere of a patient that walked 8 miles on the day you sent him home and had to correct for this. I’m one of those guys… I felt so great initially that I visited work on day 3 after my op (involved a 20min subway ride, walked in the building, lied down for 2-3 hours on couches with some short walking in corridors, and a short subway ride home, which was difficult (weak back near the end)… it was way too much and caused brutal inflammation for two days, I paid dearly for it). AFAIK my doc said this was possibly from the noxious materials near the disc that are still being emitted from it that cause inflammation, and not reherniation. I calmed down, and a few days later I went through another 18 hours of inflammaion/pain. So then I just laid down for 4-5 days and didn’t more nor walk other than going to the bathroom, with no pain, and it hasn’t returned since (3 weeks post-op).

2. I guess this begs another question: what are sure-fire signs of early reherniation after op? Because of that pain I experienced after my operation, on my 2-week follow-up visit I expected a follow-up MRI from my surgeon to be sure; I described all these things to him, but my surgeon said “if you had reherniated, you would be in severe pain that does not go away for weeks, so we don’t need to check.” (BTW I’m generally very happy with the surgeon, he’s knowledgeable, patient and involved in research, but my recovery has been disappointing so far, I don’t feel like I’m making linear progress. This is not a negative comment on my surgeon, not his fault.)

3. Another question that doesn’t seem to have a good clarification, and would be a great addition to your book or website, is regarding the specific NATURE of the recovery process. What is it exactly that requires healing and time, what occurs during those 6 weeks in the body? This would be interesting to know. Here are my guesses:
– The cut from the surgery is so small – my surgeon is young, I think he uses latest technique, very small incision, like a half-inch – that I have had barely any pain from it, except for those very rare occasional times where the back has been recruited since the op. So it’s probably not muscle repair.
– There was a laminotomy required to get through, maybe the bones need to somehow heal? Maybe that causes tiredness in the back, as tissue readjusts around the new space?
– Is it that the annulus itself beings some sort of healing process? I reason that it’s not that, because it is not a vascularized membrane, so it does not heal. Or does it somehow scar, or maybe the pulposis hardens? Maybe the bits of annulus need to rub against tissue filling the space?
– Okay, so the nerve begins deinflaming right away, and then begins recovery. But that shouldn’t cause pain and tiredness in the lower back… so…
Do you have any idea what it is that makes the back “feel tired” during this period and limits the length of walks? The mechanical nature of it makes me feel like I should not feel anything beyond some minor muscle pain. I can still just walk 5-10 blocks around my apt before I need to head home. (this is 3 weeks post-op).

4. (This is a bit of a mechanical question.) Doesn’t the posterior longitudinal ligament (PLL) grow back over the annulus once the herniated material has been removed? Would that not protect against a further reherniation a bit? (It seems to me if the annulus is broken, that small bits of disc could just ooze out of there over time, what prevents more from coming out? Intuition tells me that would an awfully unstable situation, not in line with “athletes are back to their thing within 12 weeks”. Wondering how further material is prevented from just bobbing out with movement.)

5. (This is more academic than anything else.) I bought a skeleton model – ok, I know I’m a little nerdy, but I really wanted to understand the geometry of the spine, and they’re 80$ on Amazon – and on the model it looks like a surgeon could have access through the gap between the vertebra (going through the back) without a laminotomy, if going at an angle. I don’t understand why a laminotomy is necessary… it is not possible to reach through between the bones instead of having to cut through? Really just curious.

Feel free to answer these at your convenience or not, I realize this is a lot of blablabla; on the other hand, the answers might be good complements to the rest of the absolutely excellent material on your website. What you’re doing, for such a common operation, is of great service to thousands of people, Dr. Corenman!

Wow… this means that the insult to my nerve was more serious than I had imagined.
This is going to take time then…. this is all going to be regrowth/budding… I really hope my leg function returns.

I keep wondering whether I should have gone to the E/R immediately when the big disc herniation occurred, I wonder if they would have done an MRI and operated on me right there and then to decompress ASAP (my herniation was a “pretty large one” according to the specialists), and that might have lessened my nerve damage. The spine specialists I got on the phone when it happened said that the indication for emergency surgery is for cauda equina (as indicated by progressive weakness increasing and incontinence) and while that wasn’t my case, maybe they didn’t realize how intense the pain was (my thigh was twitching uncontrollably) and to just wait it out but maybe if I’d been there and they’d seen the herniated disc, maybe the emergency person would have offered the option.

There are many tragic stories of permanent damage on the internet, but few stories of recovery – maybe people who recover just don’t bother posting so the sampling is biased. Another useful addition to your most excellent website would be of testimonies of people who have recovered over different periods of time. I guess we can do that on YouTube. I don’t know. Reading like crazy right now…

Thank you so much for your time and resources, Dr.