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Hi Dr Saghafi, I Am Following Up On My Previous
Question: Hi Dr Saghafi,
I am following up on my previous consultation with you about Sciatica in right leg.
I had new MRI done on Aug 1, 2019. It said following for L4 L5:
Severe central stenosis with pinpoint narrowing the thecal sac abd obliteration of CSF signal around the cauda equina. This due to protrusion as well as severe facet arthrosis and ligamentum flavum hypertrophy. There is severe narrowing the L5 axilar sleevein the lateral recess as well as severe bilateral L4 foraminal stenosis and nerve root impingement. Cystic changes extend along the posterior margin of the seberly degenerated left facet joint.
My questions are:
1) Do you think this type of situation can fix itself with time? I already had Sciatica for 20 months. I have ready sciatica fixes itself for many people in few years.
2) Suppose I do not get surgery done and then travel to Asia for 3 weeks. This means many long and short flights and travel on rough bumpy roads.Is there a risk of some kind of emergency where the pain becomes extruciating and I need emergency treatment etc.
3) My potential surgeon at HSS says he will remove about 4 mm of lamina and also 4 mm of facet joint. He will have neurosurgeon monitoring the nerve during surgery. Surgery under microscope with 15 to 20 mm incision. Complication rate 1 percent for my health.What are the risks here in your opinion.
I really appreciate your analysis and opinions. Thank you.
I am following up on my previous consultation with you about Sciatica in right leg.
I had new MRI done on Aug 1, 2019. It said following for L4 L5:
Severe central stenosis with pinpoint narrowing the thecal sac abd obliteration of CSF signal around the cauda equina. This due to protrusion as well as severe facet arthrosis and ligamentum flavum hypertrophy. There is severe narrowing the L5 axilar sleevein the lateral recess as well as severe bilateral L4 foraminal stenosis and nerve root impingement. Cystic changes extend along the posterior margin of the seberly degenerated left facet joint.
My questions are:
1) Do you think this type of situation can fix itself with time? I already had Sciatica for 20 months. I have ready sciatica fixes itself for many people in few years.
2) Suppose I do not get surgery done and then travel to Asia for 3 weeks. This means many long and short flights and travel on rough bumpy roads.Is there a risk of some kind of emergency where the pain becomes extruciating and I need emergency treatment etc.
3) My potential surgeon at HSS says he will remove about 4 mm of lamina and also 4 mm of facet joint. He will have neurosurgeon monitoring the nerve during surgery. Surgery under microscope with 15 to 20 mm incision. Complication rate 1 percent for my health.What are the risks here in your opinion.
I really appreciate your analysis and opinions. Thank you.
Hi Dr Saghafi,
I am following up on my previous consultation with you about Sciatica in right leg.
I had new MRI done on Aug 1, 2019. It said following for L4 L5:
Severe central stenosis with pinpoint narrowing the thecal sac abd obliteration of CSF signal around the cauda equina. This due to protrusion as well as severe facet arthrosis and ligamentum flavum hypertrophy. There is severe narrowing the L5 axilar sleevein the lateral recess as well as severe bilateral L4 foraminal stenosis and nerve root impingement. Cystic changes extend along the posterior margin of the seberly degenerated left facet joint.
My questions are:
1) Do you think this type of situation can fix itself with time? I already had Sciatica for 20 months. I have ready sciatica fixes itself for many people in few years.
2) Suppose I do not get surgery done and then travel to Asia for 3 weeks. This means many long and short flights and travel on rough bumpy roads.Is there a risk of some kind of emergency where the pain becomes extruciating and I need emergency treatment etc.
3) My potential surgeon at HSS says he will remove about 4 mm of lamina and also 4 mm of facet joint. He will have neurosurgeon monitoring the nerve during surgery. Surgery under microscope with 15 to 20 mm incision. Complication rate 1 percent for my health.What are the risks here in your opinion.
I really appreciate your analysis and opinions. Thank you.
I am following up on my previous consultation with you about Sciatica in right leg.
I had new MRI done on Aug 1, 2019. It said following for L4 L5:
Severe central stenosis with pinpoint narrowing the thecal sac abd obliteration of CSF signal around the cauda equina. This due to protrusion as well as severe facet arthrosis and ligamentum flavum hypertrophy. There is severe narrowing the L5 axilar sleevein the lateral recess as well as severe bilateral L4 foraminal stenosis and nerve root impingement. Cystic changes extend along the posterior margin of the seberly degenerated left facet joint.
My questions are:
1) Do you think this type of situation can fix itself with time? I already had Sciatica for 20 months. I have ready sciatica fixes itself for many people in few years.
2) Suppose I do not get surgery done and then travel to Asia for 3 weeks. This means many long and short flights and travel on rough bumpy roads.Is there a risk of some kind of emergency where the pain becomes extruciating and I need emergency treatment etc.
3) My potential surgeon at HSS says he will remove about 4 mm of lamina and also 4 mm of facet joint. He will have neurosurgeon monitoring the nerve during surgery. Surgery under microscope with 15 to 20 mm incision. Complication rate 1 percent for my health.What are the risks here in your opinion.
I really appreciate your analysis and opinions. Thank you.
The name of procedure is Lamino foraminotomy L4 L5.
The name of procedure is Lamino foraminotomy L4 L5.
Brief Answer:
50% of compressive radiculopathies expected to spontaneously improve
Detailed Answer:
Many thanks for your repeat inquiry. I do have some recollection of your previous questions but the system is not providing me with enough history of your prior consultations with doctors on this network for me to easily pull up what MY RESPONSES were to you and the specifics of your situation back when you first posed the question. Therefore, I apologize for that deficiency of not being able to review my previous answers. I will be answering your present questions then, based upon the information currently presented.
It would be very nice if I could read the ENTIRE MRI report as you've copied out since sometimes there are details in the body of the document (not just the conclusion or impression section) that give the reader a bit more insight. However, essentially there appears to be quite compelling radiographic evidence of a significant amount of compression of the nerve root at L4/L5 with a remarkable amount of arthritic degenerative change at that level.
Do you have results from any electrical studies that may have been done on the back or that left leg that might correlate with the observed ANATOMICAL changes and pathology being seen by the radiologist? I take it your primary symptom of import to you is PAIN? Are there symptoms of actual foot weakness on the left, history of stumbles, or falls, or sensations of numbness, tingling, or other odd feelings in the buttocks or farther downstream toward the foot consistent with impingement of the sciatic nerve itself or are your symptoms purely related to the compression of either L4 or L5 nerve root components?
Regarding your 1st question of the spontaneous healing of what we would refer to as COMPRESSIVE NEUROPATHIES or COMPRESSIVE RADICULOPATHIES (perhaps more appropriate in your case if pain is the main feature of presentation)....I very well may have quoted a statistic referred to and found in the Neurosurgical HANDBOOK authored by Green et al that states a spontaneous resolution of neuropathic or radiculopathic symptoms in people with COMPRESSIVE PATHOLOGIES on the order of approximately 50% and that these resolutions can take up to several years to accomplish. And so, YES...there are a percentage of people (according to Green and colleagues) PLUS I have in my clinical experience treated patients with compressive radiculopathies who have deferred surgery and gone on over time to have a reduction in their symptoms. I will tell you that many less than the quoted 50% have improved as far as I've SEEN in my clinics and office but..YES, I think that with AGGRESSIVE PHYSICAL REHABILITATION therapy and a dedicated patient who is willing to follow regimens of aquatherapy, daily back and leg exercises (even though there may be PAIN of an important nature), and who is also treated with CONSERVATIVE medications for pain that things can potentially improve and maybe even resolve without the need for surgical decompression.
I mainly try and educate my patients on avoiding surgery if there is NO DEMONSTRABLE MUSCLE WEAKNESS in the distribution of interest, NO MUSCLE ATROPHY, and PAIN is at a level that can be tolerated sufficiently to be productive, participate in therapies, and relatively controlled with appropriate medications (not necessarily narcotic agents either). I'm also not a huge fan of trigger point injections or steroid injections since for most patients I've not seen long term success and some even spiral out of control to the point where they are literally being injected every several weeks which is not an acceptable regimen for that sort of treatment plan....you get the idea.
Question #2: This is a difficult question to answer. Of course, surgery and its after effects can also result in unexpected or unwanted complications of pain, infections, poor healing status requiring some sort of revision by the surgeon, etc. I don't think I could give you a very scientific answer on the NUMBER you may be looking for the purpose of deciding whether or not travel to distant location is LIKELY not to result in some bad or painful complication. I think that if you had any type of decompressive surgery done and you could possibly delay such a trip which sounds like it certainly would be rough on ANYBODY'S BACK and spinal column for at least 2-3 months AFTER the surgeon considers the procedure to have HEALED....please read that again, "2-3 MONTHS AFTER SURGERY HAS HEALED"....then, I believe you stand a much less chance of the types of complications you're talking about. And especially for the fact that it is only going to be done at the L4/L5 junction. If it were going to be a multilevel decompression that might UP the risk factor for complications down the road but as it turns out it is only contemplated to be a one level procedure.
Even better yet....if you were giving consideration to going to the conservative route and waiting to see if things could heal on their own....how about simply waiting to go on your trip and get that set of circumstances OUT OF THE WAY and then, after you've come home and you know you can dedicate at least the next few months to rehabilitating and healing from a back surgery....going down that path if you feel that things simply need to be taken care of for comfort's sake...or what have you? I think that is preferable to doing the surgery then, HOPING that nothing could happen while out in Asia....nobody will be able to predict that one with decent certainty.
Question #3 This is an evolving science in and of itself and while its benefits are many in terms of being able to help spinal surgeons better place things like plates and screws so they do not interfere with nerve function or cause irritation of the nerve roots involved it is something for which the surgeon and the monitoring neurophysiologist (usually a neurologist experienced in reading such records in an Operating Room setting) BOTH must be very well trained and experienced in for this to really be worth the time, effort, and cost of having another person added to the procedure with additional monitoring equipment and technology. The monitoring physician must be very comfortable with EMG signals caused by artifact vs. those that represent some type of "in the moment" damage or irritation so that the surgeon can take corrective actions.
In our academic facilities such procedures of intraoperative neurophysiological monitoring are rarely done for adult foraminotomies or laminectomies. The need for such complex monitoring has been supplanted in many cases by MINIMALLY INVASIVE procedures that are becoming more and more commonplace as opposed to radical open procedures that have more associated complications and are more difficult from a rehabilitation perspective. It sounds as if your surgeon feels that an open procedure is more appropriate for your case. Or has there been any discussion on whether or not a minimally invasive procedure could be utilized in your situation?
Since our institutions do not order these procedures except in challenging or complex cases such as pediatric scoliosis repairs or multilevel dorsal column repairs in adults with distorted anatomy I don't have very much experience in my own patients to relate to you. All I can say is that if your center is well trained and experienced and they are using up to date criteria for such monitoring then, it can be quite beneficial. Otherwise, it may not be necessary in the majority of cases as I've explained above.
If I've provided useful and helpful information to your questions could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating if you feel so inclined? Again, many thanks for submitting your inquiry and please let me know how things turn out.
Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others. I'm very interested in knowing how things evolve for you so please drop me a line and let me know how things turn out.
This query has utilized a total of 65 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
50% of compressive radiculopathies expected to spontaneously improve
Detailed Answer:
Many thanks for your repeat inquiry. I do have some recollection of your previous questions but the system is not providing me with enough history of your prior consultations with doctors on this network for me to easily pull up what MY RESPONSES were to you and the specifics of your situation back when you first posed the question. Therefore, I apologize for that deficiency of not being able to review my previous answers. I will be answering your present questions then, based upon the information currently presented.
It would be very nice if I could read the ENTIRE MRI report as you've copied out since sometimes there are details in the body of the document (not just the conclusion or impression section) that give the reader a bit more insight. However, essentially there appears to be quite compelling radiographic evidence of a significant amount of compression of the nerve root at L4/L5 with a remarkable amount of arthritic degenerative change at that level.
Do you have results from any electrical studies that may have been done on the back or that left leg that might correlate with the observed ANATOMICAL changes and pathology being seen by the radiologist? I take it your primary symptom of import to you is PAIN? Are there symptoms of actual foot weakness on the left, history of stumbles, or falls, or sensations of numbness, tingling, or other odd feelings in the buttocks or farther downstream toward the foot consistent with impingement of the sciatic nerve itself or are your symptoms purely related to the compression of either L4 or L5 nerve root components?
Regarding your 1st question of the spontaneous healing of what we would refer to as COMPRESSIVE NEUROPATHIES or COMPRESSIVE RADICULOPATHIES (perhaps more appropriate in your case if pain is the main feature of presentation)....I very well may have quoted a statistic referred to and found in the Neurosurgical HANDBOOK authored by Green et al that states a spontaneous resolution of neuropathic or radiculopathic symptoms in people with COMPRESSIVE PATHOLOGIES on the order of approximately 50% and that these resolutions can take up to several years to accomplish. And so, YES...there are a percentage of people (according to Green and colleagues) PLUS I have in my clinical experience treated patients with compressive radiculopathies who have deferred surgery and gone on over time to have a reduction in their symptoms. I will tell you that many less than the quoted 50% have improved as far as I've SEEN in my clinics and office but..YES, I think that with AGGRESSIVE PHYSICAL REHABILITATION therapy and a dedicated patient who is willing to follow regimens of aquatherapy, daily back and leg exercises (even though there may be PAIN of an important nature), and who is also treated with CONSERVATIVE medications for pain that things can potentially improve and maybe even resolve without the need for surgical decompression.
I mainly try and educate my patients on avoiding surgery if there is NO DEMONSTRABLE MUSCLE WEAKNESS in the distribution of interest, NO MUSCLE ATROPHY, and PAIN is at a level that can be tolerated sufficiently to be productive, participate in therapies, and relatively controlled with appropriate medications (not necessarily narcotic agents either). I'm also not a huge fan of trigger point injections or steroid injections since for most patients I've not seen long term success and some even spiral out of control to the point where they are literally being injected every several weeks which is not an acceptable regimen for that sort of treatment plan....you get the idea.
Question #2: This is a difficult question to answer. Of course, surgery and its after effects can also result in unexpected or unwanted complications of pain, infections, poor healing status requiring some sort of revision by the surgeon, etc. I don't think I could give you a very scientific answer on the NUMBER you may be looking for the purpose of deciding whether or not travel to distant location is LIKELY not to result in some bad or painful complication. I think that if you had any type of decompressive surgery done and you could possibly delay such a trip which sounds like it certainly would be rough on ANYBODY'S BACK and spinal column for at least 2-3 months AFTER the surgeon considers the procedure to have HEALED....please read that again, "2-3 MONTHS AFTER SURGERY HAS HEALED"....then, I believe you stand a much less chance of the types of complications you're talking about. And especially for the fact that it is only going to be done at the L4/L5 junction. If it were going to be a multilevel decompression that might UP the risk factor for complications down the road but as it turns out it is only contemplated to be a one level procedure.
Even better yet....if you were giving consideration to going to the conservative route and waiting to see if things could heal on their own....how about simply waiting to go on your trip and get that set of circumstances OUT OF THE WAY and then, after you've come home and you know you can dedicate at least the next few months to rehabilitating and healing from a back surgery....going down that path if you feel that things simply need to be taken care of for comfort's sake...or what have you? I think that is preferable to doing the surgery then, HOPING that nothing could happen while out in Asia....nobody will be able to predict that one with decent certainty.
Question #3 This is an evolving science in and of itself and while its benefits are many in terms of being able to help spinal surgeons better place things like plates and screws so they do not interfere with nerve function or cause irritation of the nerve roots involved it is something for which the surgeon and the monitoring neurophysiologist (usually a neurologist experienced in reading such records in an Operating Room setting) BOTH must be very well trained and experienced in for this to really be worth the time, effort, and cost of having another person added to the procedure with additional monitoring equipment and technology. The monitoring physician must be very comfortable with EMG signals caused by artifact vs. those that represent some type of "in the moment" damage or irritation so that the surgeon can take corrective actions.
In our academic facilities such procedures of intraoperative neurophysiological monitoring are rarely done for adult foraminotomies or laminectomies. The need for such complex monitoring has been supplanted in many cases by MINIMALLY INVASIVE procedures that are becoming more and more commonplace as opposed to radical open procedures that have more associated complications and are more difficult from a rehabilitation perspective. It sounds as if your surgeon feels that an open procedure is more appropriate for your case. Or has there been any discussion on whether or not a minimally invasive procedure could be utilized in your situation?
Since our institutions do not order these procedures except in challenging or complex cases such as pediatric scoliosis repairs or multilevel dorsal column repairs in adults with distorted anatomy I don't have very much experience in my own patients to relate to you. All I can say is that if your center is well trained and experienced and they are using up to date criteria for such monitoring then, it can be quite beneficial. Otherwise, it may not be necessary in the majority of cases as I've explained above.
If I've provided useful and helpful information to your questions could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating if you feel so inclined? Again, many thanks for submitting your inquiry and please let me know how things turn out.
Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others. I'm very interested in knowing how things evolve for you so please drop me a line and let me know how things turn out.
This query has utilized a total of 65 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Brief Answer:
50% of compressive radiculopathies expected to spontaneously improve
Detailed Answer:
Many thanks for your repeat inquiry. I do have some recollection of your previous questions but the system is not providing me with enough history of your prior consultations with doctors on this network for me to easily pull up what MY RESPONSES were to you and the specifics of your situation back when you first posed the question. Therefore, I apologize for that deficiency of not being able to review my previous answers. I will be answering your present questions then, based upon the information currently presented.
It would be very nice if I could read the ENTIRE MRI report as you've copied out since sometimes there are details in the body of the document (not just the conclusion or impression section) that give the reader a bit more insight. However, essentially there appears to be quite compelling radiographic evidence of a significant amount of compression of the nerve root at L4/L5 with a remarkable amount of arthritic degenerative change at that level.
Do you have results from any electrical studies that may have been done on the back or that left leg that might correlate with the observed ANATOMICAL changes and pathology being seen by the radiologist? I take it your primary symptom of import to you is PAIN? Are there symptoms of actual foot weakness on the left, history of stumbles, or falls, or sensations of numbness, tingling, or other odd feelings in the buttocks or farther downstream toward the foot consistent with impingement of the sciatic nerve itself or are your symptoms purely related to the compression of either L4 or L5 nerve root components?
Regarding your 1st question of the spontaneous healing of what we would refer to as COMPRESSIVE NEUROPATHIES or COMPRESSIVE RADICULOPATHIES (perhaps more appropriate in your case if pain is the main feature of presentation)....I very well may have quoted a statistic referred to and found in the Neurosurgical HANDBOOK authored by Green et al that states a spontaneous resolution of neuropathic or radiculopathic symptoms in people with COMPRESSIVE PATHOLOGIES on the order of approximately 50% and that these resolutions can take up to several years to accomplish. And so, YES...there are a percentage of people (according to Green and colleagues) PLUS I have in my clinical experience treated patients with compressive radiculopathies who have deferred surgery and gone on over time to have a reduction in their symptoms. I will tell you that many less than the quoted 50% have improved as far as I've SEEN in my clinics and office but..YES, I think that with AGGRESSIVE PHYSICAL REHABILITATION therapy and a dedicated patient who is willing to follow regimens of aquatherapy, daily back and leg exercises (even though there may be PAIN of an important nature), and who is also treated with CONSERVATIVE medications for pain that things can potentially improve and maybe even resolve without the need for surgical decompression.
I mainly try and educate my patients on avoiding surgery if there is NO DEMONSTRABLE MUSCLE WEAKNESS in the distribution of interest, NO MUSCLE ATROPHY, and PAIN is at a level that can be tolerated sufficiently to be productive, participate in therapies, and relatively controlled with appropriate medications (not necessarily narcotic agents either). I'm also not a huge fan of trigger point injections or steroid injections since for most patients I've not seen long term success and some even spiral out of control to the point where they are literally being injected every several weeks which is not an acceptable regimen for that sort of treatment plan....you get the idea.
Question #2: This is a difficult question to answer. Of course, surgery and its after effects can also result in unexpected or unwanted complications of pain, infections, poor healing status requiring some sort of revision by the surgeon, etc. I don't think I could give you a very scientific answer on the NUMBER you may be looking for the purpose of deciding whether or not travel to distant location is LIKELY not to result in some bad or painful complication. I think that if you had any type of decompressive surgery done and you could possibly delay such a trip which sounds like it certainly would be rough on ANYBODY'S BACK and spinal column for at least 2-3 months AFTER the surgeon considers the procedure to have HEALED....please read that again, "2-3 MONTHS AFTER SURGERY HAS HEALED"....then, I believe you stand a much less chance of the types of complications you're talking about. And especially for the fact that it is only going to be done at the L4/L5 junction. If it were going to be a multilevel decompression that might UP the risk factor for complications down the road but as it turns out it is only contemplated to be a one level procedure.
Even better yet....if you were giving consideration to going to the conservative route and waiting to see if things could heal on their own....how about simply waiting to go on your trip and get that set of circumstances OUT OF THE WAY and then, after you've come home and you know you can dedicate at least the next few months to rehabilitating and healing from a back surgery....going down that path if you feel that things simply need to be taken care of for comfort's sake...or what have you? I think that is preferable to doing the surgery then, HOPING that nothing could happen while out in Asia....nobody will be able to predict that one with decent certainty.
Question #3 This is an evolving science in and of itself and while its benefits are many in terms of being able to help spinal surgeons better place things like plates and screws so they do not interfere with nerve function or cause irritation of the nerve roots involved it is something for which the surgeon and the monitoring neurophysiologist (usually a neurologist experienced in reading such records in an Operating Room setting) BOTH must be very well trained and experienced in for this to really be worth the time, effort, and cost of having another person added to the procedure with additional monitoring equipment and technology. The monitoring physician must be very comfortable with EMG signals caused by artifact vs. those that represent some type of "in the moment" damage or irritation so that the surgeon can take corrective actions.
In our academic facilities such procedures of intraoperative neurophysiological monitoring are rarely done for adult foraminotomies or laminectomies. The need for such complex monitoring has been supplanted in many cases by MINIMALLY INVASIVE procedures that are becoming more and more commonplace as opposed to radical open procedures that have more associated complications and are more difficult from a rehabilitation perspective. It sounds as if your surgeon feels that an open procedure is more appropriate for your case. Or has there been any discussion on whether or not a minimally invasive procedure could be utilized in your situation?
Since our institutions do not order these procedures except in challenging or complex cases such as pediatric scoliosis repairs or multilevel dorsal column repairs in adults with distorted anatomy I don't have very much experience in my own patients to relate to you. All I can say is that if your center is well trained and experienced and they are using up to date criteria for such monitoring then, it can be quite beneficial. Otherwise, it may not be necessary in the majority of cases as I've explained above.
If I've provided useful and helpful information to your questions could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating if you feel so inclined? Again, many thanks for submitting your inquiry and please let me know how things turn out.
Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others. I'm very interested in knowing how things evolve for you so please drop me a line and let me know how things turn out.
This query has utilized a total of 65 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
50% of compressive radiculopathies expected to spontaneously improve
Detailed Answer:
Many thanks for your repeat inquiry. I do have some recollection of your previous questions but the system is not providing me with enough history of your prior consultations with doctors on this network for me to easily pull up what MY RESPONSES were to you and the specifics of your situation back when you first posed the question. Therefore, I apologize for that deficiency of not being able to review my previous answers. I will be answering your present questions then, based upon the information currently presented.
It would be very nice if I could read the ENTIRE MRI report as you've copied out since sometimes there are details in the body of the document (not just the conclusion or impression section) that give the reader a bit more insight. However, essentially there appears to be quite compelling radiographic evidence of a significant amount of compression of the nerve root at L4/L5 with a remarkable amount of arthritic degenerative change at that level.
Do you have results from any electrical studies that may have been done on the back or that left leg that might correlate with the observed ANATOMICAL changes and pathology being seen by the radiologist? I take it your primary symptom of import to you is PAIN? Are there symptoms of actual foot weakness on the left, history of stumbles, or falls, or sensations of numbness, tingling, or other odd feelings in the buttocks or farther downstream toward the foot consistent with impingement of the sciatic nerve itself or are your symptoms purely related to the compression of either L4 or L5 nerve root components?
Regarding your 1st question of the spontaneous healing of what we would refer to as COMPRESSIVE NEUROPATHIES or COMPRESSIVE RADICULOPATHIES (perhaps more appropriate in your case if pain is the main feature of presentation)....I very well may have quoted a statistic referred to and found in the Neurosurgical HANDBOOK authored by Green et al that states a spontaneous resolution of neuropathic or radiculopathic symptoms in people with COMPRESSIVE PATHOLOGIES on the order of approximately 50% and that these resolutions can take up to several years to accomplish. And so, YES...there are a percentage of people (according to Green and colleagues) PLUS I have in my clinical experience treated patients with compressive radiculopathies who have deferred surgery and gone on over time to have a reduction in their symptoms. I will tell you that many less than the quoted 50% have improved as far as I've SEEN in my clinics and office but..YES, I think that with AGGRESSIVE PHYSICAL REHABILITATION therapy and a dedicated patient who is willing to follow regimens of aquatherapy, daily back and leg exercises (even though there may be PAIN of an important nature), and who is also treated with CONSERVATIVE medications for pain that things can potentially improve and maybe even resolve without the need for surgical decompression.
I mainly try and educate my patients on avoiding surgery if there is NO DEMONSTRABLE MUSCLE WEAKNESS in the distribution of interest, NO MUSCLE ATROPHY, and PAIN is at a level that can be tolerated sufficiently to be productive, participate in therapies, and relatively controlled with appropriate medications (not necessarily narcotic agents either). I'm also not a huge fan of trigger point injections or steroid injections since for most patients I've not seen long term success and some even spiral out of control to the point where they are literally being injected every several weeks which is not an acceptable regimen for that sort of treatment plan....you get the idea.
Question #2: This is a difficult question to answer. Of course, surgery and its after effects can also result in unexpected or unwanted complications of pain, infections, poor healing status requiring some sort of revision by the surgeon, etc. I don't think I could give you a very scientific answer on the NUMBER you may be looking for the purpose of deciding whether or not travel to distant location is LIKELY not to result in some bad or painful complication. I think that if you had any type of decompressive surgery done and you could possibly delay such a trip which sounds like it certainly would be rough on ANYBODY'S BACK and spinal column for at least 2-3 months AFTER the surgeon considers the procedure to have HEALED....please read that again, "2-3 MONTHS AFTER SURGERY HAS HEALED"....then, I believe you stand a much less chance of the types of complications you're talking about. And especially for the fact that it is only going to be done at the L4/L5 junction. If it were going to be a multilevel decompression that might UP the risk factor for complications down the road but as it turns out it is only contemplated to be a one level procedure.
Even better yet....if you were giving consideration to going to the conservative route and waiting to see if things could heal on their own....how about simply waiting to go on your trip and get that set of circumstances OUT OF THE WAY and then, after you've come home and you know you can dedicate at least the next few months to rehabilitating and healing from a back surgery....going down that path if you feel that things simply need to be taken care of for comfort's sake...or what have you? I think that is preferable to doing the surgery then, HOPING that nothing could happen while out in Asia....nobody will be able to predict that one with decent certainty.
Question #3 This is an evolving science in and of itself and while its benefits are many in terms of being able to help spinal surgeons better place things like plates and screws so they do not interfere with nerve function or cause irritation of the nerve roots involved it is something for which the surgeon and the monitoring neurophysiologist (usually a neurologist experienced in reading such records in an Operating Room setting) BOTH must be very well trained and experienced in for this to really be worth the time, effort, and cost of having another person added to the procedure with additional monitoring equipment and technology. The monitoring physician must be very comfortable with EMG signals caused by artifact vs. those that represent some type of "in the moment" damage or irritation so that the surgeon can take corrective actions.
In our academic facilities such procedures of intraoperative neurophysiological monitoring are rarely done for adult foraminotomies or laminectomies. The need for such complex monitoring has been supplanted in many cases by MINIMALLY INVASIVE procedures that are becoming more and more commonplace as opposed to radical open procedures that have more associated complications and are more difficult from a rehabilitation perspective. It sounds as if your surgeon feels that an open procedure is more appropriate for your case. Or has there been any discussion on whether or not a minimally invasive procedure could be utilized in your situation?
Since our institutions do not order these procedures except in challenging or complex cases such as pediatric scoliosis repairs or multilevel dorsal column repairs in adults with distorted anatomy I don't have very much experience in my own patients to relate to you. All I can say is that if your center is well trained and experienced and they are using up to date criteria for such monitoring then, it can be quite beneficial. Otherwise, it may not be necessary in the majority of cases as I've explained above.
If I've provided useful and helpful information to your questions could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating if you feel so inclined? Again, many thanks for submitting your inquiry and please let me know how things turn out.
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This query has utilized a total of 65 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you for your detailed analysis as always.
I had an EMG done and it showed that the pain was coming from L5 nerve root.
The MRI report has only one more note as impression about L4 L5: Severe central stenosis as well as severe impingement on the L5 axillary sleeves and severe bilateral L4 foraminal stenosis.
1) You had previously also said that upto 50 percent can get better without surgery. Is my stenosis etc on MRI significantly worse than average. Will my chances of fixing things without surgery be much less than average?
2)If I travel to Asia before my surgery, Is there say even a 1 percent chance of emergency situation arising ?
3) I am having minimally invasive surgery with a microscope. Incision size is only about 1.8 cm. Lamina removal and facet joint shaving are each on the order of 0.4 cm. It is the best I could find among multiple surgeons. Any thoughts ?
Thank you very much.
I had an EMG done and it showed that the pain was coming from L5 nerve root.
The MRI report has only one more note as impression about L4 L5: Severe central stenosis as well as severe impingement on the L5 axillary sleeves and severe bilateral L4 foraminal stenosis.
1) You had previously also said that upto 50 percent can get better without surgery. Is my stenosis etc on MRI significantly worse than average. Will my chances of fixing things without surgery be much less than average?
2)If I travel to Asia before my surgery, Is there say even a 1 percent chance of emergency situation arising ?
3) I am having minimally invasive surgery with a microscope. Incision size is only about 1.8 cm. Lamina removal and facet joint shaving are each on the order of 0.4 cm. It is the best I could find among multiple surgeons. Any thoughts ?
Thank you very much.
Thank you for your detailed analysis as always.
I had an EMG done and it showed that the pain was coming from L5 nerve root.
The MRI report has only one more note as impression about L4 L5: Severe central stenosis as well as severe impingement on the L5 axillary sleeves and severe bilateral L4 foraminal stenosis.
1) You had previously also said that upto 50 percent can get better without surgery. Is my stenosis etc on MRI significantly worse than average. Will my chances of fixing things without surgery be much less than average?
2)If I travel to Asia before my surgery, Is there say even a 1 percent chance of emergency situation arising ?
3) I am having minimally invasive surgery with a microscope. Incision size is only about 1.8 cm. Lamina removal and facet joint shaving are each on the order of 0.4 cm. It is the best I could find among multiple surgeons. Any thoughts ?
Thank you very much.
I had an EMG done and it showed that the pain was coming from L5 nerve root.
The MRI report has only one more note as impression about L4 L5: Severe central stenosis as well as severe impingement on the L5 axillary sleeves and severe bilateral L4 foraminal stenosis.
1) You had previously also said that upto 50 percent can get better without surgery. Is my stenosis etc on MRI significantly worse than average. Will my chances of fixing things without surgery be much less than average?
2)If I travel to Asia before my surgery, Is there say even a 1 percent chance of emergency situation arising ?
3) I am having minimally invasive surgery with a microscope. Incision size is only about 1.8 cm. Lamina removal and facet joint shaving are each on the order of 0.4 cm. It is the best I could find among multiple surgeons. Any thoughts ?
Thank you very much.
Brief Answer:
Many thanks for your updates and clarifications
Detailed Answer:
As I understand things the L5 nerve root is showing signs of irritation and/or compression which is the pain and paresthesias you are experiencing. Perhaps, there is some muscle weakness affecting movements of the left foot.
Apparently, the EMG does not seem to be detecting any electrical abnormalities in the L4 nerve root. Therefore, the surgeon does have the option of not surgerizing the L4 nerve root for decompression purposes even though MRI suggests the presence of degenerative arthritic disease in its proximity. You and the surgeon could have a discussion on this point. Keep in mind that FIXING things that aren't broken YET can always be done in the future if necessary whereas trying to be proactive NOW by decompressing L4 on the basis of MRI information may be thought to be the equivalent of "poking the bear" if that cliche analogy makes sense to you.
My advice to my patients has always been to do the minimum amount of surgery necessary (minimally invasive included) to resolve ACTUAL DOCUMENTED PROBLEMS and no more. If things are normal in nature and function even though they APPEAR to be otherwise, I will always lean toward ACCEPTING that awkward appearance in place of FIXING it and then, possibly dealing with the consequences of having performed surgery on nerves, muscle, and other connective tissue which then, will have a scarring effect which then, can lead to adhesions, involvement of other nerves and nerve roots above that level that were never involved before (i.e. L3)...well, you get my point?
To your additional questions:
1. There is no specification from the quote I gave of the 50% spontaneous recovery statistic as to the initial severity of the patients suffering from the radiculopathy problems. My experience using patients I've seen and treated who have experienced spontaneous recovery without surgical interventions seems to be tied to their response and dedication to performing regular and aggressive PHYSICAL REHABILITATION. Patients who respond to the therapy approach and keep daily logs of pain levels charted against activity levels do best at controlling and even dramatically lowering them while improving activities and productivity. They don't become PAIN FREE but they become dramatically better after several months or several years of dedicated rehab, losing weight, stopping smoking, eating more healthy diets, strengthening core abdominal musculature, etc. In these patients the chance of not needing surgery is better and independent of the severity of initial symptoms or what images may show.
2. As far as your complication rates after surgery please remember that I've never performed such surgeries because I am a neurologist. The better source of information on complication rates following surgery (without or without trips to rugged lands away from home) would be the doctor who you have consulted for this purpose. I've already said in the previous response that I believe THERE IS a potential for complication following ANY SURGERY. My best advice (and the one I'd choose for myself) would be to either defer the trip until having fully recovered and rehabilitated from surgery OR deferring the surgery until after this trip which as you've described would be taxing even for a fully healthy person WITHOUT back problems, no?
3. Happy to hear that the surgery is a minimally invasive procedure and I agree with your choice of procedure. In our institution we almost never utilize IOM with a neuromuscular physiologist unless it's a complex pediatric case or in an adult perhaps a revision with pedicle plates and screws that appear to have come out of place, etc. Our minimally invasive surgeons are quite adept at screw placements and results are very good without such monitoring. Again, in the right hands it can have benefits but by the same token with an excellent surgeon directing the procedure, possibly unnecessary according to what I've seen.
All the best as always and please keep in informed as to what you finally decide upon and what your progress is with either surgery or dedicated therapy. Cheers and safe travels as well.
This query has utilized a total of 100 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Many thanks for your updates and clarifications
Detailed Answer:
As I understand things the L5 nerve root is showing signs of irritation and/or compression which is the pain and paresthesias you are experiencing. Perhaps, there is some muscle weakness affecting movements of the left foot.
Apparently, the EMG does not seem to be detecting any electrical abnormalities in the L4 nerve root. Therefore, the surgeon does have the option of not surgerizing the L4 nerve root for decompression purposes even though MRI suggests the presence of degenerative arthritic disease in its proximity. You and the surgeon could have a discussion on this point. Keep in mind that FIXING things that aren't broken YET can always be done in the future if necessary whereas trying to be proactive NOW by decompressing L4 on the basis of MRI information may be thought to be the equivalent of "poking the bear" if that cliche analogy makes sense to you.
My advice to my patients has always been to do the minimum amount of surgery necessary (minimally invasive included) to resolve ACTUAL DOCUMENTED PROBLEMS and no more. If things are normal in nature and function even though they APPEAR to be otherwise, I will always lean toward ACCEPTING that awkward appearance in place of FIXING it and then, possibly dealing with the consequences of having performed surgery on nerves, muscle, and other connective tissue which then, will have a scarring effect which then, can lead to adhesions, involvement of other nerves and nerve roots above that level that were never involved before (i.e. L3)...well, you get my point?
To your additional questions:
1. There is no specification from the quote I gave of the 50% spontaneous recovery statistic as to the initial severity of the patients suffering from the radiculopathy problems. My experience using patients I've seen and treated who have experienced spontaneous recovery without surgical interventions seems to be tied to their response and dedication to performing regular and aggressive PHYSICAL REHABILITATION. Patients who respond to the therapy approach and keep daily logs of pain levels charted against activity levels do best at controlling and even dramatically lowering them while improving activities and productivity. They don't become PAIN FREE but they become dramatically better after several months or several years of dedicated rehab, losing weight, stopping smoking, eating more healthy diets, strengthening core abdominal musculature, etc. In these patients the chance of not needing surgery is better and independent of the severity of initial symptoms or what images may show.
2. As far as your complication rates after surgery please remember that I've never performed such surgeries because I am a neurologist. The better source of information on complication rates following surgery (without or without trips to rugged lands away from home) would be the doctor who you have consulted for this purpose. I've already said in the previous response that I believe THERE IS a potential for complication following ANY SURGERY. My best advice (and the one I'd choose for myself) would be to either defer the trip until having fully recovered and rehabilitated from surgery OR deferring the surgery until after this trip which as you've described would be taxing even for a fully healthy person WITHOUT back problems, no?
3. Happy to hear that the surgery is a minimally invasive procedure and I agree with your choice of procedure. In our institution we almost never utilize IOM with a neuromuscular physiologist unless it's a complex pediatric case or in an adult perhaps a revision with pedicle plates and screws that appear to have come out of place, etc. Our minimally invasive surgeons are quite adept at screw placements and results are very good without such monitoring. Again, in the right hands it can have benefits but by the same token with an excellent surgeon directing the procedure, possibly unnecessary according to what I've seen.
All the best as always and please keep in informed as to what you finally decide upon and what your progress is with either surgery or dedicated therapy. Cheers and safe travels as well.
This query has utilized a total of 100 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Brief Answer:
Many thanks for your updates and clarifications
Detailed Answer:
As I understand things the L5 nerve root is showing signs of irritation and/or compression which is the pain and paresthesias you are experiencing. Perhaps, there is some muscle weakness affecting movements of the left foot.
Apparently, the EMG does not seem to be detecting any electrical abnormalities in the L4 nerve root. Therefore, the surgeon does have the option of not surgerizing the L4 nerve root for decompression purposes even though MRI suggests the presence of degenerative arthritic disease in its proximity. You and the surgeon could have a discussion on this point. Keep in mind that FIXING things that aren't broken YET can always be done in the future if necessary whereas trying to be proactive NOW by decompressing L4 on the basis of MRI information may be thought to be the equivalent of "poking the bear" if that cliche analogy makes sense to you.
My advice to my patients has always been to do the minimum amount of surgery necessary (minimally invasive included) to resolve ACTUAL DOCUMENTED PROBLEMS and no more. If things are normal in nature and function even though they APPEAR to be otherwise, I will always lean toward ACCEPTING that awkward appearance in place of FIXING it and then, possibly dealing with the consequences of having performed surgery on nerves, muscle, and other connective tissue which then, will have a scarring effect which then, can lead to adhesions, involvement of other nerves and nerve roots above that level that were never involved before (i.e. L3)...well, you get my point?
To your additional questions:
1. There is no specification from the quote I gave of the 50% spontaneous recovery statistic as to the initial severity of the patients suffering from the radiculopathy problems. My experience using patients I've seen and treated who have experienced spontaneous recovery without surgical interventions seems to be tied to their response and dedication to performing regular and aggressive PHYSICAL REHABILITATION. Patients who respond to the therapy approach and keep daily logs of pain levels charted against activity levels do best at controlling and even dramatically lowering them while improving activities and productivity. They don't become PAIN FREE but they become dramatically better after several months or several years of dedicated rehab, losing weight, stopping smoking, eating more healthy diets, strengthening core abdominal musculature, etc. In these patients the chance of not needing surgery is better and independent of the severity of initial symptoms or what images may show.
2. As far as your complication rates after surgery please remember that I've never performed such surgeries because I am a neurologist. The better source of information on complication rates following surgery (without or without trips to rugged lands away from home) would be the doctor who you have consulted for this purpose. I've already said in the previous response that I believe THERE IS a potential for complication following ANY SURGERY. My best advice (and the one I'd choose for myself) would be to either defer the trip until having fully recovered and rehabilitated from surgery OR deferring the surgery until after this trip which as you've described would be taxing even for a fully healthy person WITHOUT back problems, no?
3. Happy to hear that the surgery is a minimally invasive procedure and I agree with your choice of procedure. In our institution we almost never utilize IOM with a neuromuscular physiologist unless it's a complex pediatric case or in an adult perhaps a revision with pedicle plates and screws that appear to have come out of place, etc. Our minimally invasive surgeons are quite adept at screw placements and results are very good without such monitoring. Again, in the right hands it can have benefits but by the same token with an excellent surgeon directing the procedure, possibly unnecessary according to what I've seen.
All the best as always and please keep in informed as to what you finally decide upon and what your progress is with either surgery or dedicated therapy. Cheers and safe travels as well.
This query has utilized a total of 100 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Many thanks for your updates and clarifications
Detailed Answer:
As I understand things the L5 nerve root is showing signs of irritation and/or compression which is the pain and paresthesias you are experiencing. Perhaps, there is some muscle weakness affecting movements of the left foot.
Apparently, the EMG does not seem to be detecting any electrical abnormalities in the L4 nerve root. Therefore, the surgeon does have the option of not surgerizing the L4 nerve root for decompression purposes even though MRI suggests the presence of degenerative arthritic disease in its proximity. You and the surgeon could have a discussion on this point. Keep in mind that FIXING things that aren't broken YET can always be done in the future if necessary whereas trying to be proactive NOW by decompressing L4 on the basis of MRI information may be thought to be the equivalent of "poking the bear" if that cliche analogy makes sense to you.
My advice to my patients has always been to do the minimum amount of surgery necessary (minimally invasive included) to resolve ACTUAL DOCUMENTED PROBLEMS and no more. If things are normal in nature and function even though they APPEAR to be otherwise, I will always lean toward ACCEPTING that awkward appearance in place of FIXING it and then, possibly dealing with the consequences of having performed surgery on nerves, muscle, and other connective tissue which then, will have a scarring effect which then, can lead to adhesions, involvement of other nerves and nerve roots above that level that were never involved before (i.e. L3)...well, you get my point?
To your additional questions:
1. There is no specification from the quote I gave of the 50% spontaneous recovery statistic as to the initial severity of the patients suffering from the radiculopathy problems. My experience using patients I've seen and treated who have experienced spontaneous recovery without surgical interventions seems to be tied to their response and dedication to performing regular and aggressive PHYSICAL REHABILITATION. Patients who respond to the therapy approach and keep daily logs of pain levels charted against activity levels do best at controlling and even dramatically lowering them while improving activities and productivity. They don't become PAIN FREE but they become dramatically better after several months or several years of dedicated rehab, losing weight, stopping smoking, eating more healthy diets, strengthening core abdominal musculature, etc. In these patients the chance of not needing surgery is better and independent of the severity of initial symptoms or what images may show.
2. As far as your complication rates after surgery please remember that I've never performed such surgeries because I am a neurologist. The better source of information on complication rates following surgery (without or without trips to rugged lands away from home) would be the doctor who you have consulted for this purpose. I've already said in the previous response that I believe THERE IS a potential for complication following ANY SURGERY. My best advice (and the one I'd choose for myself) would be to either defer the trip until having fully recovered and rehabilitated from surgery OR deferring the surgery until after this trip which as you've described would be taxing even for a fully healthy person WITHOUT back problems, no?
3. Happy to hear that the surgery is a minimally invasive procedure and I agree with your choice of procedure. In our institution we almost never utilize IOM with a neuromuscular physiologist unless it's a complex pediatric case or in an adult perhaps a revision with pedicle plates and screws that appear to have come out of place, etc. Our minimally invasive surgeons are quite adept at screw placements and results are very good without such monitoring. Again, in the right hands it can have benefits but by the same token with an excellent surgeon directing the procedure, possibly unnecessary according to what I've seen.
All the best as always and please keep in informed as to what you finally decide upon and what your progress is with either surgery or dedicated therapy. Cheers and safe travels as well.
This query has utilized a total of 100 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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