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Treatment for L5/S1 migrated disc fragment

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I have spent the past two years of my life working hard at attaining what I consider an elevated level of health and fitness. To be precise, I took off 60 LBs, lowered my blood pressure and cholesterol and increased my stamina and strength. A big part of my life has been the reintroduction of athletic activities. I love to golf, run, play basketball and practice a martial art (Ju Jitsu). I also like my strength and conditioning program which has included weight and core training.

About 9 weeks ago I ruptured my L5/S1 disk while lowering my 8 month old into his stroller. It was a momentary lapse of focus since I have had back pain in the past and I am very cognizant of proper technique for lifting. Within a minute or two intense sciatica radiated down my right leg and into my foot. I was incapacitated for a day and immediately sought medical attention. The sciatica was diagnosed as a suspected disc herniation. I did not have an MRI right away but was prescribed physical therapy and some chiropractic care. After examination by the Physical Therapist and a Pain Management Doctor, I was found to have some loss of motor function in my right big toe.

The PT worked wonders. Within a week I was able to walk and move about for relatively long distances without pain. Within a few more weeks, my range of motion and intensity of movement improved dramatically. At that time (about 4 weeks into my treatment) I had an MRI which revealed I actually had two herniations: one at L3/L4 and one at L5/S1 which was extruded. There is a migrated fragment with the extruded disc.

Since then my condition has continued to improve. I have regained much, but not all, motor function in the big toe. The numbness is relegated only to the big toe and has decreased significantly. I have great range of movement in my back before any sciatic pain appears.

I have conservatively increased my fitness program and can now run 5K at about 85-90% of the pace I was at before the injury. I am able to lift weights at 90-95% of the weight I was at pre-injury, although I am sticking to the machines and have not tried free weights yet. I do all this pain-free.

The doctors and therapist are thrilled with the results and we have ruled out many treatment options besides the conservative care treatment I have been doing. However the migrated fragment still leaves the question of a laminectomy open.

If I want to live without some of my pre-injury activities, then surgery is clearly not recommended. But I want to return to my activities, all of them. So here is where I am unsure of how to proceed and I am seeking advice.

There are risks and benefits to the two courses of action I can take:

-Stick with conservative care - it is always good to avoid surgery. I can avoid the risk of something going wrong with the surgery as unlikely as that may be. I stand to lose less disc height. I won’t have to have any bone removed and any spinal instability that may result. I avoid post-operative recovery and care. The fragment remains which means I may never recover any disability I am experiencing now. And with my activities I could cause the fragment become an acute problem, which means I’m looking at the knife anyway.

-Get the laminectomy – This gives me the best chance to recover fully enough to resume all my activities. But, I will lose more disc height and will now be further at risk for disc herniations in the future. I will lose bone and there is the potential for spinal instability. Then there is the post-operative recovery.

My inclination is to avoid surgery, but considering the lifestyle I wish to retain I am caught in a dilemma. I am soliciting advice and opinions. And if anyone has further factors I should be considering, I am all ears.
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replied October 23rd, 2009
Extremely eHealthy
First of all, before you actually consider surgery, you should get a second and even a third opinion on what would be the best course of treatment for you, both short and long term.

Second, there isn't a reason to do a full laminectomy to remove that disc fragment, if that is what you decide to do. I assume that is why you mentioned a laminectomy.

A skilled orthopedic surgeon who specializes in spines and is well experienced would also be well informed and experienced in doing a far less invasive procedure called a laminotomy, which is becoming the preferred procedure for decompression, microdisectomy and removal of disc fragments.

In a laminectomy, the entire laminia is removed to reach the area of the disc. By doing this, it can create havoc, long term, with the spine and cause instability. If you have any future problems with another disc at another level, then doing a second laminectomy could destablize the spine and require a fusion.

When a laminotomy is done, only a very small piece of the lamina is removed, just enough to gain access to the disc. It can be done on one side of the lamina or on both sides. The risk of the spine becoming unstable with a laminotomy is minimal. Also, more than one laminotomy can be done on different levels and still maintain a stable spine.

Laminotomy also doesn't carry the increased risk of disc herniations either.

Another thought as well. Spine surgery should be the last option chosen when there are spinal issues. As with any surgery, there are always risks, including anesthesia, and yes, creating further problems with the spine.

Though, most people recover from spine surgery and go on with their lives, as I have, regardless, whether you have spine surgery or not, your spine will really never be the same as it was before any injury to it.

You will always have the potential for further problems, if for no other reason than you already have had one.

You have to be careful with your spine, continue to do all the core exercises that your learned to do in physical therapy and do them for the rest of your life.

Having been in the situation where no conservative measures helped me at all, I had no alternative but to have a laminotomy done to relieve the pressure on nerves in my L4/L5.

I fully recovered and returned to being able to do about 95% of my prior activities.

Had it not been for an auto accident a few years later, I wouldn't have ended up with a disc bulge at the L3/L4 that required a second laminotomy and microdisection as well.

Even after that though, I full recovered and again returned to the same 95% activity.

If given the choice you are having right now, and knowing that I had a chance for surgery in the end, but also have done well with conservative measures. Well, I would continue with the conservative measures and wait it out. You may never need the surgery and then again you might.

But either way, please get at least one more opinion, I got 7 others before I had my first surgery, and please discuss the option of having a laminotomy instead of the laminectomy.

Avoiding having the full lamina removed is something that should be done unless there are absolutely no other alternatives.

Good luck and keep us posted.

Fran
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replied October 23rd, 2009
Thanks for the response Fran.

You are right, I am looking at a Laminotomy not a Laminectomy. I was told that the procedure would only remove a small piece of bone. But the goal is to get the fragment out since it is highly suspected as the cause of what disability I am exeriencing now.

I am holding out hope that my condition continues to improve and this becomes a moot point. But I am concerned that I may be close to a plataeu and a return to the activities I love will require the surgery.

My doctor has also suggested a second and third opinion. So I am going to pursue that as well and may even take it for a few more opinions after that.

Thanks again.
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replied December 2nd, 2009
Spinal disc fragments
I have a disc fragment on my L2 / L3 pressing on the nerve root causing severe pain. Dr. suggested pain management via spinal injections first to see if my body will eventually absorb the bone fragment. Surgery would be last option in his opinion if bone fragment is not absorbed and then only to ensure no permanent damage to nerve. What is your opinion of pain management injections?
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replied December 3rd, 2009
Extremely eHealthy
Re: Spinal disc fragments
debntexas wrote:
I have a disc fragment on my L2 / L3 pressing on the nerve root causing severe pain. Dr. suggested pain management via spinal injections first to see if my body will eventually absorb the bone fragment. Surgery would be last option in his opinion if bone fragment is not absorbed and then only to ensure no permanent damage to nerve. What is your opinion of pain management injections?


I'm all for it, and wish it could have, would have helped me avoid even one surgery. I gave it a try, 3 injections of 3 months and the most relief I got was 24 hours.

My symptoms progressed very, very rapidly. Onset was sudden, fine when I went to bed, couldn't get out of be the next morning. Within 4 months the nerve compression became so severe that I lost full bladder control and had I not had surgery scheduled for the next morning, it would have been done as an emergency that next morning.

The key is try all conservative measures first and give the body a chance to heal itself. Things like physical therapy, steroid injections that are done by a well trained pain doctor that uses floroscopy to do them, and then and only then consider surgery if the conservative measures fail.

That is unless your symptoms continue to worsen, or you start to have symptoms of cauda equina, loss of bowel/bladder control. Then surgery is an emergency as the nerves will become permanently damaged if the compression isn't removed with in 24 hours.

Also, if the conservative measures don't work and surgery is the next step, you should get at least 1 other, preferably more than one other opinion before agreeing to surgery.

Good luck

Fran
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replied December 3rd, 2009
Update: After 4 months, my progress has plateaued. I have stopped running (which I now realize I shouldn't have forced to begin with), but have maintained my conservative care and maintained but modified my fitness regime.

Now the nitty gritty: I got another MRI recently and my migrated fragment has gotten smaller, but is still there and is pressing against the nerve root. The L5-S1 protrusion is bigger and is now pressing against the left side as well causing a minor decrease in sensation and according to one doctor a very minor weakness. I also have a minor protrusion on L3-L4 (which was on the original MRI) and now L4-L5 is showing a very, very minor bulge.

I have seen 3 surgeons, 2 of whihch are vehemetly advocating for microdiscectomy on L5-S1. One even yelled at me, to which I have not seen him since. But I have cut back on the pain med/NSAID in lieu of Tylenol (as recommended by the last surgeon). And I am feeling more radicular pain in the leg since. It is tolerable and aerobic exercise on a staionary bike or elliptical machine tends to help relieve the pain.

But I am perplexed. The original surgeon who has seen me since the beginning is leery of surgery considering all the progress I have made. But two subsequent opinions have been absolutely in favor of the surgery.

Each have a different opinion on the extent of the neurological deficit in my right foot. But all agree that there is definitely a deficit. Each have a different take on the risks I am taking by not having the surgery. Each are also of a different opinion on what will happen to the migrated fragment. They all come with excellent credentials and references, but I don't know what to make of it all.

I am scheduled for the microdiscectomy on December 16th, but can easily back out if I want to. I am trying to weigh all the factors, but the conflicting infomation is daunting and disheartening.

All I want to do is get better and return to as much of my life as it was before I got hurt.
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replied May 24th, 2010
Well I read all about this & think this is my problem. This Dr did nerve root injections & I wound up worse then I was before. I had a bad fall & an MRI that does show a small free disc fragment at L5S1. I never thought anything about it & he never mentioned it. My pain is so bad in lower back around by groin & down thigh it is terrible. I hate pain killers but have to take them once in awhile it hurts so much. It has ruined my whole life. I've been searching for answers & put free disc fragment in google & got your posts. This may be whats causing it. I'm gonna print it all out & go see an ortho Dr who has a great record. What can happen if it was ignored?
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replied May 24th, 2010
The outcomes from conservative care and surgery over the course of two years is about the same. The thing you have to be worried about is the fragment. When the blood and water finally gets absorbed by the body the remaining nucleous pulposis is left. This is a hard fragment and can cause problems. If it is left for too long (more than 9 months) it will calcify and surgery will be much more difficult to perform.

The outcome for my surgery was good and bad. Here's the good: the radicular pain has essentially gone away. I get a touch of it from time to time, but its not real pain, just a reminder. The neuroligocal deficit is still there but is much less significant. I can move my toe upwards with some but not all of my previous strength. The numbness is almost all gone.

Here's the bad: my lower back is sore. It is always sore in the morning and subsides as the day goes on. I do not have the same range of motion or strength in my lower back despite a lot of core conditioning.

The doctor tells me that the slight return of the radicular pain and the soreness is caused by scarring. Scarring is an inevitability. The effects of scarring, however, is different for everyone. Some people do not feel any ill effects and return to full strength and range of motion. Some people are like me. But everyone is different.

I am only 5+ months removed from the surgery and my soreness is improving every day/week. I am told that it will take a good 6 months to a year before it will subside to a minimal level. I am holding out hope that a little more time represents a significant improvement from where I am today.

So, if you have a migrated fragment and you have worsening pain and/or neurological deficit that is not improving, it is worthwhile to get a few opinions from neurosurgeons. You can also go to Orthopedic surgeons as well. But I would see at least one neurosurgeon.

Good luck.
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replied May 24th, 2010
Lumbar Disc Fragment, 3 surgeries
I have had surgeries on l3/l4 because of a disc fragment that dislodged into the spinal canal. I lived with pain for about 5 years and about every 2 or 3 months my back would spasm and "go out" which would require about a week in the bed before I could function again. After about 5 years of this routine I had the surgery and felt great. Because I waited so long for the first surgery the rest of my lumbar was guarded and naturally protected itself through immobilization. With this came degeneration and now all my lumbar discs are pretty rotten looking. 2 years after my first surgery I herniated L5's1 and L4/l5, went as long as I could with PT, epidurals etc. Finally when I could no longer function in life I had 2 more Discectomy's/Laminectomy's. Again felt great for 2 years. Always had arthritic type pain and occasionally I would wake up crooked, but could manage. Always very fit and my good friend is a PT which helps make PT a way of life. 3 months ago during routine PT I felt a little tweak in my back and it instantly swelled and 3 days later had severe sciatica through my groin, side of hip, down leg. After 4 weeks of conservative accute exercise therapy I went to see the doc, who prescribed oral steroid. Didn't work. The next week I did epidurals, in 4 levels. 80% pain was gone but still very nagging. Now it is back after 7 weeks as severe as ever, maybe worse, disrupting every aspect of life. After all of that there are a couple of points from my experience. I feel like if I didn't wait so long to have that fragment removed initially, the rest of my discs would be in a lot better condition. I wasted so much of my life in Pain and the surgery took care of it. On the other hand I am in bad shape now and have had 3 levels of Discectomies. Many procedures are contraindicated after you have had a surgery so keep that in mind. I'm not even 40 and really scared about my future. Headed to Scripps next week to explore options.
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replied May 25th, 2010
This happened around set 2009 so it's not new. What gets me is so many Dr's including the one who did the nerve block injections (that made me so much worse) SAW THAT ON THE mri & NEVER SAID A WORD ABOUT IT AT ALL!
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replied May 25th, 2010
another question Being that this happened Sep09,2009 should this be taken care of right away? Just how dangerous is this, now I have to wait till June 8th. I have been getting bad pains in my neck on one side.
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replied May 26th, 2010
I think with the sciatic hip and leg pain you are probably fine until then if that is what your doctor is saying. I'm sure that seems like an eternity from now. Neck pain probably isn't from l5/s1, so not good.
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