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Neurology (Expert Forum)
Is this severe a surgery warranted? Surgery scheduled for 4/21/00
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Is this severe a surgery warranted? Surgery scheduled for 4/21/00
by Carolyn, Apr 19, 2000 12:00AM
I am a 31 year old female with a history of a L5-S1 hemilaminectomy in 1991 and L5-S1 fusion in 1993. Recently, I have experienced increased nerve pain in the buttocks and down both legs. In addition, when sitting erect, if I move my lower back slightly, I can feel the bones move.
I was originally injured while in the US Navy and as such, the neurosurgeon from the NNMC in Bethesda, MD will be performing the operation at Walter Reed AMC on Friday - two days! (If you know the doctor, please do not tell him I wrote in as I don't want him to think I doubt his opinion.) They want to perform a L2-S1 fusion - removing all but the verterbral body, use pedicle screws and rods and bone from the bone bank to fuse the area. My concern is that this seems very intrusive and would just like to know if it seems appropriate. I cannot go on with the pain I have been experiencing, which has been increasing in severity almost parabolically since Nov. 1999, so I know I need to have something done.
I pushed to have the thoracic MRI due to radiating pain I experience at around the T11-T12 level - the level at which the back brace from the second operation ended. The doctor tells me the pain I have there is reference pain, but I am not sure I agree. I just found out about the bulging disks in the thoracic region - of which the doctor wasn't aware of before. I experienced a time when I had diarrhea for about six months and now only comes once in a while. I originally thought it was due to stress, however, could that be due to the herniated disks? As well, are there any questions I should ask the doctor with regard to those disks or the surgery in general? I want to make sure I am not being a guinea pig for surgeons who are preparing for private practice.
I really appreciate any advice you can provide - I have been trying to post for the past two months and while I realize, this is the 11th hour, would still like your feedback. Following are the CT scan and MRI results.
I had a CTscan in Jan.2000 - the results are:
Clinical History: The patient is a 31 year old female with a previous L5-S1 fusion (3/93). Rule out nonunion.
Technique: 3mmx2mm contiguous axial images were obtained from the inferior endplate of L2 through S1. Sagittal images were reconstructed from the axial data.
Findings: There is no evidence of a dense bone fusion between L4-L5 or L5-S1. The patient may have transitional lumbosacral anatomy.
At L2-L3, there is a circumferential disk bulge superimposed on moderate facet arthropathy with prominence of the ligamentum flava. This results in moderate to moderately severe central bony canal and bilateral subarticular recess stenosis. The neural foramina remain patent.
At L3-L4, there is a circumferential disk bulge superimposed on moderate facet arthropathy. This results in severe central bony canal and bilateral subarticular recess stenosis. The neural foramina remain patent.
At L4-L5, there has been attempted posterior decompression. There is a circumferential disk bulge with degenerative endplate changes. Due to bone overgrowth, there is significant stenosis of the right subarticular recess. There is compromise to the traversing right L5 nerve root. The central bony canal and left subarticular recess are patent. The neural foramina are patent.
At L5-S1, there is facet arthropathy resulting in bilateral subarticular recess stenosis with compromise to the traversing S1 nerve roots. The central bony canal is mildly stenotic. The neural foramina are patent.
Impression: This patient has transitional lumbosacral anatomy. Comparison should be made with plain films should surgical intervention be contemplated. As numbered, the patient has significant spondylarthropathy at L2-3 and L3-4 resulting in significant central bony canal and bilateral subarticular recess stenosis. There has been surgery at L4-5. With bone overgrowth on the right, there is significant right subarticular recess stenosis with compromise to the traversing right L5 nerve root.
At L5-S1, there is bilateral subarticular recess stenosis.
There is no evidence of a dense anterior fusion at either L4-5 or L5-S1.
I had an MRI in March, 2000, the results are:
MRI of Thoracic and lumbar spine:
History: Back and flank pain. Attempted L5-S1 PSF after failed back surgery eight years ago. Now with severe stenosis and DJD. MRI for preoperative planning.
Procedure: Through the thoracic spine, sagittal T1 and sagittal fast spin echo T2-weighted images were obtained. Through the lumbar spine, sagittal T1, sagittal fast spin echo/dual echo T2, axial T1, axial fast spin echo T2, and post-gadolinium axial and sagittal T1-weighted images were obtained.
Findings: Thoracic spinal cord is of normal signal intensity throughout. Conus ends at the mid T12 level. At T4-T5, there is a small central disk bulge. At T5-T6, there may be a small right paracentral disk protrusion. At T6-T7, there may be a small disk bulge. At T10-T11, there is a small central disk bulge. The thoracic spine marrow signal intensity is normal. Alignment is normal.
The remaining visible structures about the thoracic spine are unremarkable.
Sagittal images: The L5 vertebral body is transitional. There is a rudimentary L5-S1 intervertebral disk. Conus ends at the mid T12 level and is of normal signal intensity and configuration. No abnormal pial enhancement. Cauda equina is unremarkable. The L2-L3 and especially L3-L4 intervertebral disks are diminished in signal intensity and height, and bulge diffusely. Central disk protrusion at L2-L3 and a central disk herniation at L3-L4. At the L4-L5 level, there has been a right hemilaminectomy and partial resection posterior aspect of the L4-L5 disk. This portion of the disk enhances and is compatible with scar. Minimal degenerative endplate change at L4-L5. Marrow signal intensity otherwise normal. Lumbar spine alignment normal.
Axial images: The L5-S1 disk is rudimentary. L5 is sacralized.
At L4-L5, there has been a right hemilaminectomy. Posterior aspect of the disk space demonstrates increased T2 signal intensity and enhancement following administration of gadolinium. This is contiguous with T1 signal abnormality material in left anterior epidural space and left subarticular recess surrounding the anterior and posterior aspects of traversing left L5 nerve root. This material enhances and is compatible with scar. No displacement of traversing nerve roots. Traversing left L5 nerve root sleeve is mildly distended. Signal intensity in the anterior aspect of the L4-L5 disk is diminished, as is height. There is no evidence of fusion across the disk space. Central canal is widely patent, the left subarticular recess is narrow but not truly stenotic, right subarticular recess is mildly to moderately stenotic and the neural foramina are widely patent bilaterally.
At L3-L4, there is a central disk herniation superimposed on the broad-based disk bulge and mild bilateral facet arthropathy with narrowing of the transverse dimension between the facets. Central canal is at least moderately stenotic, subarticular recesses are moderately stenotic bilaterally, and the neural foramina are mildly stenotic bilaterally.
At L2-L3, there is a broad-based disk bulge with small superimposed broad-based central anular tear with protrusion. Central canal is moderately stenotic, subarticular recesses moderately stenotic, and the neural foramina are at least mildly stenotic bilaterally.
At L1-L2, the disk is normal. The central canal and neural foramina are widely patent.
The remaining visible structures about the lumbar spine are unremarkable.
Impression:
1. Suggestion of small mid-thoracic disk protrusions.
2. Probable transitional anatomy with L5 being sacralized.
3. Post surgical changes at L4-L5 based on spine level numbering from the dens. Scar formation in left paracentral region. No evidence of recurrent disk herniation.
4. Central disk herniation L3-L4 which may affect bilateral traversing L4 nerve roots and which causes significant central canal stenosis. Further evaluation is recommended.
5. Additional spondylotic changes causing central stenosis at L2-L3.
I was originally injured while in the US Navy and as such, the neurosurgeon from the NNMC in Bethesda, MD will be performing the operation at Walter Reed AMC on Friday - two days! (If you know the doctor, please do not tell him I wrote in as I don't want him to think I doubt his opinion.) They want to perform a L2-S1 fusion - removing all but the verterbral body, use pedicle screws and rods and bone from the bone bank to fuse the area. My concern is that this seems very intrusive and would just like to know if it seems appropriate. I cannot go on with the pain I have been experiencing, which has been increasing in severity almost parabolically since Nov. 1999, so I know I need to have something done.
I pushed to have the thoracic MRI due to radiating pain I experience at around the T11-T12 level - the level at which the back brace from the second operation ended. The doctor tells me the pain I have there is reference pain, but I am not sure I agree. I just found out about the bulging disks in the thoracic region - of which the doctor wasn't aware of before. I experienced a time when I had diarrhea for about six months and now only comes once in a while. I originally thought it was due to stress, however, could that be due to the herniated disks? As well, are there any questions I should ask the doctor with regard to those disks or the surgery in general? I want to make sure I am not being a guinea pig for surgeons who are preparing for private practice.
I really appreciate any advice you can provide - I have been trying to post for the past two months and while I realize, this is the 11th hour, would still like your feedback. Following are the CT scan and MRI results.
I had a CTscan in Jan.2000 - the results are:
Clinical History: The patient is a 31 year old female with a previous L5-S1 fusion (3/93). Rule out nonunion.
Technique: 3mmx2mm contiguous axial images were obtained from the inferior endplate of L2 through S1. Sagittal images were reconstructed from the axial data.
Findings: There is no evidence of a dense bone fusion between L4-L5 or L5-S1. The patient may have transitional lumbosacral anatomy.
At L2-L3, there is a circumferential disk bulge superimposed on moderate facet arthropathy with prominence of the ligamentum flava. This results in moderate to moderately severe central bony canal and bilateral subarticular recess stenosis. The neural foramina remain patent.
At L3-L4, there is a circumferential disk bulge superimposed on moderate facet arthropathy. This results in severe central bony canal and bilateral subarticular recess stenosis. The neural foramina remain patent.
At L4-L5, there has been attempted posterior decompression. There is a circumferential disk bulge with degenerative endplate changes. Due to bone overgrowth, there is significant stenosis of the right subarticular recess. There is compromise to the traversing right L5 nerve root. The central bony canal and left subarticular recess are patent. The neural foramina are patent.
At L5-S1, there is facet arthropathy resulting in bilateral subarticular recess stenosis with compromise to the traversing S1 nerve roots. The central bony canal is mildly stenotic. The neural foramina are patent.
Impression: This patient has transitional lumbosacral anatomy. Comparison should be made with plain films should surgical intervention be contemplated. As numbered, the patient has significant spondylarthropathy at L2-3 and L3-4 resulting in significant central bony canal and bilateral subarticular recess stenosis. There has been surgery at L4-5. With bone overgrowth on the right, there is significant right subarticular recess stenosis with compromise to the traversing right L5 nerve root.
At L5-S1, there is bilateral subarticular recess stenosis.
There is no evidence of a dense anterior fusion at either L4-5 or L5-S1.
I had an MRI in March, 2000, the results are:
MRI of Thoracic and lumbar spine:
History: Back and flank pain. Attempted L5-S1 PSF after failed back surgery eight years ago. Now with severe stenosis and DJD. MRI for preoperative planning.
Procedure: Through the thoracic spine, sagittal T1 and sagittal fast spin echo T2-weighted images were obtained. Through the lumbar spine, sagittal T1, sagittal fast spin echo/dual echo T2, axial T1, axial fast spin echo T2, and post-gadolinium axial and sagittal T1-weighted images were obtained.
Findings: Thoracic spinal cord is of normal signal intensity throughout. Conus ends at the mid T12 level. At T4-T5, there is a small central disk bulge. At T5-T6, there may be a small right paracentral disk protrusion. At T6-T7, there may be a small disk bulge. At T10-T11, there is a small central disk bulge. The thoracic spine marrow signal intensity is normal. Alignment is normal.
The remaining visible structures about the thoracic spine are unremarkable.
Sagittal images: The L5 vertebral body is transitional. There is a rudimentary L5-S1 intervertebral disk. Conus ends at the mid T12 level and is of normal signal intensity and configuration. No abnormal pial enhancement. Cauda equina is unremarkable. The L2-L3 and especially L3-L4 intervertebral disks are diminished in signal intensity and height, and bulge diffusely. Central disk protrusion at L2-L3 and a central disk herniation at L3-L4. At the L4-L5 level, there has been a right hemilaminectomy and partial resection posterior aspect of the L4-L5 disk. This portion of the disk enhances and is compatible with scar. Minimal degenerative endplate change at L4-L5. Marrow signal intensity otherwise normal. Lumbar spine alignment normal.
Axial images: The L5-S1 disk is rudimentary. L5 is sacralized.
At L4-L5, there has been a right hemilaminectomy. Posterior aspect of the disk space demonstrates increased T2 signal intensity and enhancement following administration of gadolinium. This is contiguous with T1 signal abnormality material in left anterior epidural space and left subarticular recess surrounding the anterior and posterior aspects of traversing left L5 nerve root. This material enhances and is compatible with scar. No displacement of traversing nerve roots. Traversing left L5 nerve root sleeve is mildly distended. Signal intensity in the anterior aspect of the L4-L5 disk is diminished, as is height. There is no evidence of fusion across the disk space. Central canal is widely patent, the left subarticular recess is narrow but not truly stenotic, right subarticular recess is mildly to moderately stenotic and the neural foramina are widely patent bilaterally.
At L3-L4, there is a central disk herniation superimposed on the broad-based disk bulge and mild bilateral facet arthropathy with narrowing of the transverse dimension between the facets. Central canal is at least moderately stenotic, subarticular recesses are moderately stenotic bilaterally, and the neural foramina are mildly stenotic bilaterally.
At L2-L3, there is a broad-based disk bulge with small superimposed broad-based central anular tear with protrusion. Central canal is moderately stenotic, subarticular recesses moderately stenotic, and the neural foramina are at least mildly stenotic bilaterally.
At L1-L2, the disk is normal. The central canal and neural foramina are widely patent.
The remaining visible structures about the lumbar spine are unremarkable.
Impression:
1. Suggestion of small mid-thoracic disk protrusions.
2. Probable transitional anatomy with L5 being sacralized.
3. Post surgical changes at L4-L5 based on spine level numbering from the dens. Scar formation in left paracentral region. No evidence of recurrent disk herniation.
4. Central disk herniation L3-L4 which may affect bilateral traversing L4 nerve roots and which causes significant central canal stenosis. Further evaluation is recommended.
5. Additional spondylotic changes causing central stenosis at L2-L3.
Doctor's Answer
by CCF Neuro[P] MD, RPS, Apr 19, 2000 12:00AM
Dear Carolyn:
Sorry to hear about your back problems. The things that catch my eye is the significant central canal stenosis at L3-L4 and the presence of foramen stnosis. I would place alot of blame of your radiating pain to the disc buldge compromising the cord. What did the second opinion suggest? (I hope that I am NOT your second opinion, as without actually seeing the films and doing the exam I am somewhat handicapped). Certainly, what is proposed will help the central canal stenosis
Sorry to hear about your back problems. The things that catch my eye is the significant central canal stenosis at L3-L4 and the presence of foramen stnosis. I would place alot of blame of your radiating pain to the disc buldge compromising the cord. What did the second opinion suggest? (I hope that I am NOT your second opinion, as without actually seeing the films and doing the exam I am somewhat handicapped). Certainly, what is proposed will help the central canal stenosis