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Dr. Andrew Rynne

Family Physician

Exp 50 years

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I have sciatica with pain in my right buttock, ham

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Dr. Olsi Taka

Neurologist

Practicing since :2004

Answered : 3530 Questions

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Posted on Thu, 31 Jan 2019 in Brain and Spine
Question: I have sciatica with pain in my right buttock, ham string and calf. There is no lower back pain. Recent MRI showed at L4 L5 there is a new small broad central disk protrusion. Also there is moderate to severe bilateral facet hypertrophy resulting in moderate central canal stenosis at L4 L5. I am considering a minimally invasive micro disectomy because other things like epidural injections and physical therapy have not worked.
1) Can a minimally invasive micro disectomy be done just to fix disc protrusion etc without removing or drilling through the lamina?
2)Are there any other procedures where there is no drilling through lamina or bone removal from the spine.
Thanks.
doctor
Answered by Dr. Olsi Taka 1 hour later
Brief Answer:
Laser discectomy may be considered.

Detailed Answer:
I read your question carefully and I understand your concern.

Regarding your first question about microdiscectomy, it depends on the level of visibility for the surgeon during the procedure. When possible no bone is removed, but usually there will be the necessity of removing some of the lamina (very little usually only a few millimiters, nothing to affect stability) to mediate better visibility.

As for other possibilities laser disc decompression would be another technique which is being used more and more, where a needle is inserted into the disc space and instead of removing disc material it is burned through laser. Being a relatively new technique its efficacy has not been proven in large scale studies, but small scale publications indicate it to be beneficial comparatively to other surgical procedures, so given your worry about invasive surgery you might discuss whether it is available where you live with your doctor.

I hope to have been of help.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Olsi Taka 2 hours later
Thank you very much for your answer. Your pointing me towards PLDD is extremely helpful.

1) In PLDD, is there XXXXXXX of burning the nerve in addition to the disk?

2) Can they over heat the disk creating other problems?

3)What is realistic worst case downside scenario in PLDD?

4) Do you know any good PLDD facilities in or near New York city.

Thanks.






















doctor
Answered by Dr. Olsi Taka 22 hours later
Brief Answer:
Read below.

Detailed Answer:
Hello again and sorry for answering a little late.

1. Laser treatment is administered to the disc nucleus so risk to the nerve is very low. There have been described a few cases with thermal damage to the nerve from the overheated canule which conveys the laser therapy. Very rare though and damage is reversible.

2. If the heat is administered correctly to the nucleus there is no such risk, the aim is to destroy that part not to preserve it. The problem would arise if not administered to the nucleus only but also to the surrounding anulus fibrosus.

3. The most cited complication and real risk is discitis, inflammation of the disc, which may be due to an infection or also nonifectious due to reactive inflammation. That is the most described procedure.

4. I am afraid that not living in the US I am not sure I am in a good position to recommend specific centers in New York, any recommendation would be from internet searching not personal experience with US healthcare system

One last thing, while I was the one suggesting laser discectomy to you I would like to add that I didn't do it because of any added benefit but only because of you inquiring about the least invasive method possible. There are many different approaches for discectomy, even inside one approach like laser discectomy there are differences between surgeons in technique used, however between different minimally invasive techniques possible complications are similar and generally risk is very low, you don't have to be scared by terms like drilling. At the end of the day if it is a reputable center I would leave it to the spine surgeon to choose the method he is most comfortable and has most experience with.

Let me know if I can further assist you.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Olsi Taka 1 hour later
Thanks for very informative detailed reply.

1) In your opinion, what is the overall risk of microdisectomy vs PLDD. Does microdisectomy have a extreme possible outcome like discitis?

2) My pain is managed fine with one lidocaine patch daily on the butt . Also I apply some voltaren gel on the ham string and calf area once or XXXXXXX twice a day. If it were you, will you keep going with the lidocaine and voltaren or will you go with PLDD or microdisectomy. Just your opinion.

3) In microdisectomy, are they able to work on spinal stenosis also without much bone removal.

4) It has been nine months already but can Sciatica fix itself in time ? How much time ?

Thank you.
doctor
Answered by Dr. Olsi Taka 31 minutes later
Brief Answer:
I wouldn't go for any of the procedures

Detailed Answer:
I think microdiscectomy has a higher risk of complications, however discitis is not among them, minor complications. It has a slightly higher success rate as well. However it's difficult to compare the two because there are fewer publications about PLDD, it is less widely used.

If your pain is managed with lidocaine and voltaren I wouldn't advise any of the procedures to be honest, I would stay with the medication. I do not generally recommend procedures for that type of central protrusion, not unless all medication has failed and I am certain that is the origin of the pain. Even before while I was providing info on available techniques I was a little uneasy about you thinking about a procedure as you do not mention that protrusion compressin a nerve root in the report. Some mild central protrusions are commonly found but they do not necessarily need surgery.

Microdiscectomy techniques vary, but no, I don't think it can be managed to work on that spinal stenosis due to facet hypertrophy, if it was the disc the main cause it could be hoped that its removal would help, but in this case there are other components.

Nerve damage can take up to one year to recover, even longer at times. In addition to that there are often other factors perpetuating the pain such as psychological factors and altered pain neurotransmission. That is why often medication with antidepressants or anticonvulsants which modulate pain transmission helps. There are studies which have shown similar outcome in two years for patients treated with surgery and conservatively (of course cases which needed urgent intervention not included) so there is place for improvement in time.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Olsi Taka 3 hours later
Thanks a lot. You have been extremely helpful.
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Follow up: Dr. Olsi Taka 9 minutes later
Just one clarification: You mentioned that complications in microdisectomy are minor - did I understand it right?
If something is touching the nerve, how does it heal by itself over time?
I will stay away from surgery for some time.
Thanks again.
doctor
Answered by Dr. Olsi Taka 9 hours later
Brief Answer:
Read below.

Detailed Answer:
The peripheral nervous system does have regenerative properties (unlike the central nervous system which does have very poor regenerative abilities). After damage to the axons, pathways mediating removal of the debris by the immune system and production of local growth factors are activated gradually leading to regeneration of the damaged axons. Of course it depends on the degree of damage, if completely severed say due to a trauma the result is not perfect, some deficits may remain, but in procedure like microdiscectomy the damage (if there is any damage that is) by the contact with the nerve is mild.
But I still with the current info would not advise surgery as I said before.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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