Dear Sir, The x-ray images look fine. The screws, rod and the TLIF cage looks perfectly in space. The CAT Scan report also look pretty good. Whereas the matter of concern would be the granulation tissue around the L2-3 foramen. It appears to be the body reaction for surgery. If your pain is becoming worse even with medications, then giving a transforaminal injection steroid might be an option.
I don't think your surgeon is missing on anything as per the reports sent by you.
Regards,
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Patient replied :
There is some new bone formation in
the left paracentral to foraminal region along the tract of the interbody
fusion device at L3-L4 which may narrow the left lateral recess. Correlate for
any clinical evidence of left L4 radiculopathy. I am really worried about this in the report. I don't understand how this could be normal. Is this the reason I have the pain in my leg? The pain radiates from the low left spine, left glute, outside edge to backside of quad muscle, and sharp pain in the shin. The doctor told him it was nerve regeneration pain prior to seeing the CT scan results, but then called and said everything looks fine on the CT scan. The report seems like it tells a different story. Also, the surgery was a TLIF with BMP and a PEEK inter body cage. Am I able to recover without surgery? How long is a reasonable time to wait to feel better? Thanks so much for your help. I have a copy of my cat scan disk if you tell me what to take a photo of I can post a photo so you can see it. Thank you so much for your time and help.
I clearly understand your concern. The surgical aspect what your doctor has done looks pretty impressive. I mean, he has done only a hemilaminectomy(instead of complete laminectomy) and has put a peek cage(better than titanium cage). Screw placement is perfect. Surgery wise I don't see anything wrong. Because of handling of the nerve you may have pain and parasthesias for several months 3-6 months. But as such there is no particular upper limit for the same. If it persists for longer period we need to look for other reasons for your pain. That's exactly what has happened in your case. The area of interest is definitely the left L4-5 neural foramen. In MRI it says enhancing granulation tissue and in CAT Scan it says new bone formation. Whatever it is.. It's post operative changes which we are seeing which is beyond the control of surgeon nor the patient. As these changes can be expected in few patients the foramen where the nerve travels is widened by doing a facetectomy, which was done in your case. Is the post operative changes the reason for your symptoms? Could be. Then how to handle it? I would give steroid infiltration to check the growth of granulation tissue and also to control neuralgic pain. We can wait for a good 3-6 months for the pain to settle. If not controlled beyound this period you may have to go under the knife for further neural decompression. As I have seen, resurgery should be the last and final resort in these cases.
I hope this gives you more insight.
With regards,
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Patient replied :
Dear Dr Goutham Cugati, Neurosurgeon:
Thank you for your detailed response. It definitely helped calm some fears we were having. Would you suggest having the steroid infiltration be done now or wait a couple of months? What type of infiltration is it exactly? Also, it has been just over 5 months post op now, what should he be doing as far as physical therapy and what restrictions would you still recommend. He was told he can lift 25 lbs, no excessive or repetitive twisting or bending. He even said he could use the riding mower (our yard is bumpy). The physical therapists were concerned about the increasing pain and weren't sure what to still do or not to do. He was doing lower trunk rotations, straight leg lifts, side leg lifts, side bridges, regular bridges, bridges with leg marches, marches on a ball and leg lifts on a ball, wall squats, dumbbell rows, step exercises, stationary sitting bike, and standing pull ups and push ups. He was also doing piriformis stretch, knee to chest stretch, bending with arms extended rolling a ball out and back to the left, center, and right while sitting on a bench, and a hamstring stretch. His insurance stopped covering physical therapy so now he's left on his own. Do you feel any of these are aggravating his symptoms or are ok to do? Are there any other you'd recommend? He doesn't hurt while doing them but seems like he feels worse a couple of hours later after doing them. He has also started taking Gabapentin (Neurotin) 1800 mg per day (600mg morning, noon, and night). It helps some but not much. Should it be increased or do you not feel that it would not be of much help. His insurance doesn't pay for Lyrica. Thank you for all your help, it is greatly appreciated. He has a lot of confidence in this neurosurgeon, but they are very busy and don't have the time to spare to answer any of these questions or concerns.
Hello,
Regarding steroid infiltration, if the pain is intolerable its better to get it done now.
It's called a transforaminal steroid injection which will be given under fluoroscopic guidance. This is what I usually practice in India. I am not sure about the practice in your country. As I have seen, it is given by pain therapist in the western countries only after being referred by your treating neurosurgeon.
It's better to avoid twisting n bend excessively. Mowing on a bumpy yard is better avoided.
The exercises mentioned by you can by done. But if they are hurting you much, then, do it for shorter duration.
Gabantip 1800/day is already a high dose. I don't suggest any further increase in the dose.