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Numbness and weakness of feet after back surgery.

Posted By  Juan on April 19, 1999 at 13:33:16
Topic Area: Neuromuscular

I'm starting to loose hope of ever getting an answer to the situation
I describe here. Please help me, I'm not getting any straight answers
locally where I live and am totally disoriented as to what to do next.
I can't conceive having to live the rest of my life like this.
Thank you.

  I am a 55 year old male who has undergone 2 back surgeries as a
  consequence of which both of my feet have been left substantially numb.
  My first surgery was in November 1997. It consisted of shaving off the
  protruding portion of a herniated disk at L5-S1. When I came out of the
  anesthesia, my right foot was numb and has remained so to this day. The
  performing surgeon told me that the numbness would go away in some time,
  so when a year had gone by and my right foot was still numb, I went back
  to him to see what could be done about it.
  New MRI and mylogram were done in November 1998 which revealed that the
  disk had moved and was now compressing my left sciatic nerve, and it was
  the surgeon's opinion was that even though it couldn't be observed in the
  MRI, he felt that this was the factor why my right foot was still numb,
  so he suggested another surgery to resolve that situation and restore
  the sensation to my right foot.
  I then went to an independent neurologist and his opinion coincided with
  that of the surgeon, so based on the 2 opinions, I consented to the
  second operation of L5-S1 which took place on December 21, 1998 (3 months
  ago). When I came out of the anesthesia, not only my was right foot
  still numb, but my left foot was now also numb and a mirror image of my
  right foot, with numbness in exactly the same pattern as my right foot.
  Also, the strength of my knees was substantially reduced by this second
  operation to the extent that I have difficulty going up steps without
  assisting myself up with my hands on the handrail. I also easily loose
  my balance, specially laterally and backwards, and cannot walk normally
  since I cannot flex my feet.
  The numbness is on my 2 smaller toes, the outside of each foot and also
  in the heel area. My left foot is somewhat more numb than my right foot.
  I have had knowledge that I am diabetic (Type 2) for about 7 years but
  ever since, my diabetes has been under very tight control. Nerve
  conductivity studies have been performed to determine if I have any
  neuropathy associated with my diabetes and all results have been
  negative. My glycohemoglobin quarterly tests come in at 6.50 to 6.9 at
  the very most.
  I have been undergoing physical therapy for the last 4 weeks and the
  results have been that I have somewhat more muscle control and am able
  to walk a bit closer to normal, but the numbness, lack of balance and
  weakness still persist.
  I have consulted 2 other doctors besides the surgeon who performed both
  operations; an orthopedic surgeon and a neurologist. A new mylogram was
  performed last March 8 and it shows a bulge on the left side at L5-S1
  which the 3 doctors say it could be either scar tissue or bone, they
  don't know at this time and say it can be known in about 2 months
  through another mylogram or MRI.
  I am desperate and don't know what to do, since none of the 3 doctors I
  have consulted in Tampa can tell me with certainty what has happened and
  if there is anything that can be done to restore my feet's nerves. I
  have to be on my feet extensively in my work since I am a contractor and
  have fallen three times in the last few weeks but fortunately have not
  injured myself.
  It is my understanding that the condition I have is NOT progressive, but
  then I would like for you to corroborate or rectify that for me. Can this
  condition worsen in the future or not? I have no pain associated with
  my present condition, just numbness in the areas I have described, lack
  of balance and weakness in my feet and knees. Importantly, my right leg
  calf muscle has undergone some atrophy since my first operation back in
  November 1997. It now is 2 centimeters less in circunference than my left
  calf muscle. Now that both feet are numb, I'm afraid that in time, the
  atrophy may also involve my left leg as well.
  While researching the internet for spinal related medical centers I ran
  across yours and I wonder if there is anything your staff could do for me
  and my present condition.
  I am willing to go to your center if you believe my nerves can be restored
  back to normal. The orthopedic surgeon I have in Tampa told me he would
  refer me to any medical facility I wanted to go have my condition
  independently examined. I have adequate health insurance which I imagine
  would have to pre-approve any treatment or procedure. My insurance is the  
  the PPO type, not an HMO.
  Please let me know at your convenience what your opinion is of my case,                                                                                                                                    
  what in your opinion my prognosis is, and if you believe you can further
  assist me in my case. I will more than gladly supply you with whatever
  further information you require.
  Thank you very much for your time and interest in my case, and for this
  wonderful service you provide to the community.
  Very truly yours,
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Avatar universal


Posted by CCF MD mdf on April 29, 1999 at 22:52:15
The pattern of numbness on your feet is in the distribution of the S1 nerve roots (not L5). It is, as you suspected, NOT typical of neuropathy such as you might have with diabetes (which is well controlled).
There are motor fibers in the S1 root which work some of the muscles in the lower extremity (one of them is to push the foot down at the ankle). You mentioned a degree of weakness and lack of control, and the atrophy of the calf suggests the gastrocnemius muscles (innervated by S1 nerve fibers) has been weakened.
A couple of general points:
The nerve root that gets damaged is usually one below the level at which the disc herniates. That is, if your L5 disc contributes to debris in the spinal canal, expect the S1 root to take a hit.
Some recovery is possible after nerve injuries, and even after injuries in the central nervous system (brain and spinal cord). Some of that is due to regrowth of nerve fibers (peripheral only, not central nervous system). Some of it is due to the brain reprogramming itself to adapt to the injury.
In general, if you haven't made much change by a year after damage, you will probably not make much change (better or worse) inthe future. That means you should consider with caution any surgical procedure offered in the hope of relief of this numbness.
For numbness, tingling, and pain which are really difficult to bear, we do use some medications. The sensation is not improved by the medicine, but the noxious quality is reduced. I imagine you have already tried some, but if you have not, ask your doctor about low-dose nortriptyline or imipramine, or perhaps gabapentin (Neurontin).
You certainly are welcome to come to CCF if you wish a second opinion. I am not optimistic about the prospects of future surgery, but our experts at the Spine Center are able to suggest both surgical and (more often) non-surgical treatment for patients with complicated spine problems such as yours. It's always difficult to judge whether you should travel a thousand miles at some expense just for the possibility that we can't do something, so you will have to make that decision yourself.
To make an appointment with the Spine Center, call 800 223-2273 and ask for extension 4-5559. That is neurology appointments, and it is possible they will refer you to another number, but at least it's a start.

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