New Member Considering Surgery on L5/S1

[raising4daughters]

My hunch is that some of you have been where I am, so I'd appreciate ANY advice. My lower-back pains started about 6 years ago, but were manageable and only sporadic until this past May/June. My signature carries the history and current assessment.

I have no signs of muscle or nerve weakness, but am tired after 6 months at 46 of being in pain and sedentary. My wife, 4 kids, and job are demanding and I'm a type A, impatient person and a bit of a perfectionist. I've given up running and am getting crabby. I think that's a big part of my problem.

Conservative therapies don't seem to be working well enough. I do the meds (Neurontin, although my GP wants to add Tramadol), exercises, and traction religiously. I haven not tried injections or any other invasive pain therapy. I've consulted with 3 surgeons (2 ortho, 1 neuro) in the past 2-3 weeks and have the following:

Surgeon #1 - pain management probably won't help. Getting a CT scan to help with MRI evaluate whether minimally-invasive foraminotomy and microdiscectomy will be sufficient. If he feels it won't, the he conceded that fusion would be the only other option, and he was lukewarm about recommending it. Really liked this surgeon. Spent time with me and explained everything. Great reputation locally for outcomes.

Surgeon #2 - wants me to try epidural injections and then fusion if that fails. He expressed opposition to the minimally-invasive techniques because the patient always needs a 2nd surgery (his statement). Wasn't too hot on this surgeon though I thought he was talented; felt like a number and the facility was a factory pressed for output. Doubt he'd "be there for me" if anything went wrong. Plan to drop him.

Surgeon #3 - prescribed RF Ablation rather than epidural injections. Feels this MAY help and is also a diagnostic for him on whether surgery will help. I didn't understand this, but this guy was a genius and I really like him, too. Spent 90 minutes with me. Compared anterior and posterior options with me and explained he even does fusions like mine minimally invasively, but again seemed somewhat opposed to surgery and wasn't real positive that fusion would relieve back pain, just leg pain.

All concluded that L5/S1 is the culprit with disk bulge forward and back and severe foraminal stenosis and with a minor, insignificant bulge at S1/S2. When I look at the MRI, it looks like a s'more where the marshmallow has been smushed by the 2 crackers.

Any predictions on where this is headed, outcomes from similar circumstances, or other advice would be MUCH appreciated?

[laid up doc]

Scott -

my main thought after reading your post is that it is unclear if it is the disc itself that is causing you pain.

one thing that annoys the crap out of me when surgeons do discectomies and whatnot on patients w/ back pain is that if the disc is causing you pain and the disc is not removed (and space filled in by fusion or ADR) and it is causing you PAIN... then removing the fragment or herniated part only is useless and honestly sometimes i wonder if they know it...

have you seen a pain doctor to discuss where they think your pain is coming from? in my experience, THAT is their focus, whereas the focus of the surgeon is whether to cut, where, etc.

imho the biggest mistake patients make w/ their spine is not correctly identifying their pain generator(s). if you have surgery and don't address the right pain generator, or all pain generators.... then your pain will not go away! it's becoming a pet peeve of mine... and i think that many of the bad outcomes we see on this site and others are due to inadequate pain generator identification.

[raising4daughters]

LaidupDoc - thanks for the input. I think you make a GREAT point that I hadn't considered, and that's the diagnostics learned from pain management. I agree with you that no one has pinpointed whether my pain is due to the disc, the stenosis pinchinig on the nerve roots, or the arthritic facet joints. And, the neuro pointed out that one of the vertebra (I think it was L5) has acutally fallen out of line - he speculated that muscle spasms may be pulling on it.

All in all, I think the 3 surgeons probably agree with you, but didn't express their opinion as you did - the MRI isn't conclusive as to what specifically is causing the pain. In that sense, all 3 ordered something that would give them more data, so I guess I can't complain.

Your direct way of pointing this out is really helpful. Thank you.

[laid up doc]

you are very welcome.

don't know if you've ready any of my old posts - but i was misdiagnosed for a while. so many spine patients are mis-, under-, or wrongly diagnosed b/c it takes WORK. that, and people think you go to a spine surgeon for back/neck pain and that's it. in my experience, they're the worst diagnostaticians if the answer isn't clear on an MRI.

there's a well known study out there about MRI's and back pain. basically, if you find 50 people w/ back pain and 50 people w/o back pain and MRI them all... a blinded radiologist (doesn't know who's who) can't tell who has pain and who doesn't on MRI alone. yet so many surgeons hold onto that belief... that if it isn't on the MRI, it can't be fixed.

that's where nerve blocks, discograms, etc come into play. a good pain doc who does a lot of spine imho is the best person to IDENTIFY your problem. whether surgery is the answer is then tricky, and how much should you do before having surgery for a given diagnosis, etc.... like i usually say, we're all individuals w/ individual combinations of problems. there is no one best answer or option. all any of us knows is what worked or didn't for ourselves.... though the observant and knowledgeable can see some patterns - as i mentioned above.

[raising4daughters]

I agree with you about Pain Mgt. I had good success with Pain Mgt about 6 years ago when I was one of the unlucky <1% to develop severe complications 8 months after a vasectomy. I was very fortunate to find an authority (urologist) on treating Post-Vasectomy Pain Syndrome in my hometown of Cleveland, and he worked with Pain Mgt in a relief and diagnostic way. The groin injections cut my pain by 1/3 to which my urologist then believed that I was having backpressure pain, not just nerve pain. He did a 3-1/2 hour reversal on me and I was good as new in 3 months. That pain pre-reversal was FAR worse than any back pain I've suffered thus far, often a 10 on the ol' 1-10 scale.

I think I'll work with the same group at the Cleveland Clinic's pain management center to see if they can pinpoint the pain generator(s). Truthfully, I believe it's the disk as well as the nerve roots being impinged by the stenosis. I have too many different symptoms that come and go and are started by different things and relieved by different treatments.

Again, thanks for your thoughts. At first, I was rushing to surgery. I still think I'll end up with some form of surgery, but your counsel has helped me understand that I better do my homework first.

[Cindylou]

Scott, laid up doc has really given you some sound advice. Identifying pain generators is a critical, most important piece of the puzzle. I know yours are lumbar and not cervical, but I will say, just fyi, for me personally, I get incredible relief from RF on my neck and it lasts about 14 months. Anything I can do to ward off surgery, after all my lumbar issues and surgeries, is music to my ears. Just saying. Good luck as you pursue the best treatment option for you. Cindylou

[raising4daughters]

Thanks for the input CindyLou and LaidupDoc.

Had a CT Scan and immediately saw Surgeon #1. The CT Scan convinced the doc that a discectomy and foraminotomy are all that's needed, not a full fusion. He said the skeletal area is good, but the disc is all but obliterated. The CT showed there's several air pockets where disc used to be. He said the CT scan shows the disc being more of the problem than the MRI and that the stenosis isn't as bad as initially thought, but is bad enough to warrant decompression.

He's definitely not pushing surgery, indicating several times that I'm generally healthy and have no signs of atrophy. But, with my symptoms getting progressively worse by the week -- now I can barely stand for more than a few minutes or walk more than a few steps -- he said I'll know when it's the right time.

I'm pretty darn comfortable with the conclusion but am fearful only because of the long list of people that say to avoid back surgery and the list of people that didn't get relief.

I'm dropped off the report and CT Scan (along with the MRI which he already saw) with Surgeon #3, a neuro. I'm hoping he can look at it this week and give me his opinion. He was pushing RF Ablation, but I'm not so sure about that approach. Seems like a risk in and of itself.

Any thoughts?

[raising4daughters]

CindyLou and LaidUpDoc, just wanted to give you a quick update.

Although I do trust Surgeon #1's recommendation for a discectomy and foraminotomy, I've decided to opt for Surgeon #3's path and pursue pain management in hopes of a cure or, at least, additional diagnostics.

The pain clinic yesterday indicated they believe I'm getting pain from 2 separate sources....one the herniated disc and two the left facet joint. They've recommended starting with an epidural injection targeted at the disc and related pain in the lower back and leg. If that solves some, but not all, then they feel we'll know the facet joint is the separate problem causing my "hot spot" to the left of my spine. I was impressed with their approach. And, this will satisfy Surgeon #3's pre-requisite for even considering surgery, as well.

Thanks again for your experience-based input.