Ross’ Herniated Disc Symptoms seemed to be improving.
After the injection, things were slowly feeling better over the following two weeks.
He was able to enjoy vacation, work on some lumbar extension strengthening, walk around a zoo, return to work, and went camping without any limitations. Even his symptoms were looking up: the marble he felt under his right foot was decreasing in size, he had some good improvements in his neural mobility in both his legs, and he noticed a general ease of movement as his spine could flex a little more. He didn’t think he would actually need a microdiscectomy.
Then things took a turn for the worse.
On Tuesday, July 16th (20 days after his injection), he woke up early, put weight on his feet, and his left foot went numb. Oh no. It was just my right foot going numb before, and now its my left, this isn’t good.
Ross walked downstairs to the basement, and the numbness didn’t spread. That’s hopeful at least, and there is nothing new in my right foot.
He strapped himself into his unloading harness, walked on the treadmill, and the numbness subsided in 5 minutes. Oh good, I at least have a tool to manage this mechanically. And after an hour of a combination of unloaded walking and full weight bearing walking (while watching Receiver on Netflix – It’s great, go watch it.), the numbness never returned. There is a progression of symptoms though.
Ross was psyched he had an MRI scheduled later that day.
After the MRI, Ross grabbed the CD with the images on it. He went to work early, because they actually have a slot to put a CD into.
Looking at the images, he noticed his disc protrusion had progressed quite a bit. There really was no room for his spinal cord.
The L4/5 Disc herniation is progressing. From December ’23 to July ’24. The nucleus (white part inside the disc) is starting to become sequestered as well. Once it is sequestered, the body’s immune system can more easily reabsorb the disc material, reducing the pressure on the nerves. There also is just not much space for the nerves descending down the spinal canal, as the nerves appear black as they are being pushed together, rather than grey with white in between, as seen above.
Ross was beginning to think he would need a microdiscectomy sooner rather than later. His symptoms however, were stable for the time being. He was able to move his neurosurgeon appointment up to tomorrow. His symptoms remained the same the rest of the day and things were pretty uneventful.
Until 1am the next morning…
Ross woke up, maybe due to increased leg pain, or maybe to go pee. Either way, both those sensations were present. He stood up, walked to the bathroom, peed, and his left foot went numb again. Uhh. It’s too early to walk on my treadmill. I’ll try taking a Valium and go back to sleep.
For 30 minutes, Ross rolled around in bed from position to position, unable to get his foot symptoms to subside, and a tightness started to creep down from his glutes to his hamstrings. Alright, I guess I’ll head down and walk since it’s feeling a little worse.
Ross stood up. Oh no… I really have to go to the bathroom.
Ross sat on the toilet. Oh god. I really have to go, but nothing is going to come out. This doesn’t make sense – I just went pee. Shit. My hamstrings are tight as hell now too. I’ve got to get downstairs now.
In about 10 minutes of unloaded walking the urge subsided. Okay. So. This wasn’t a loss of control of bowel or bladder which would send me to the Emergency Department for a discectomy, right? And it improved. I also don’t have any saddle anesthesia. Maybe I’m okay? I did have a change in bowel and bladder sensation though… My Left foot is still really numb though too.
Walking for another 20 or 30 minutes alleviated Ross’ foot symptoms. That took way longer than yesterday. This is getting much worse. At least I have an appointment with neurosurgery later today.
Once things felt pretty stable, he walked back upstairs, laid on his stomach on a thin pad on the floor, and his symptoms of tightness were centralized to his lower back only. This feels super tight, but at least the tightness is in my back. I don’t think I’ll fall asleep here though… Let’s try lying on my back…. I guess that feels okay with my legs straight out, but I definitely can’t bend them or lie on my side without symptoms running down both legs.
After sleeping for maybe another two hours, Ross had to call into work.
His left foot was numb again when he got up, and it took awhile to calm down with unloaded walking. The numbness also returned when he was full weight bearing again.
He was on and off walking on the treadmill for a majority of the morning, waiting to call the neurosurgery clinic, then waiting for a call back. When he got a hold of them, they recommended emergency care as the surgeon he was going to see was going on vacation this evening, and his partner was also on vacation until next week. Shit. I don’t think I can wait that long for surgery. I need to go now, and I’ll see whoever.
Time for Emergency Microdiscectomy
Ross was luckily able to squeeze in an appointment with a Neurosurgeon at Boulder Community Hospital. Upon review of the MRI, his reported symptoms from the previous night, and undergoing proper myotome testing with the neurosurgeon, that disc had to come out right away as the spinal cord compression has even advanced beyond “severe” to “critical”. Yeah I agree. Let’s do this microdiscectomy.
On the Left, circled in green, you can see individual nerves (darker) speckled in the spinal canal (white). Compared to the right, there isn’t enough space to make out the individual nerves and they appear as a solid grey.
The neurosurgeon had an opening in 4 hours and a microdiscectomy would take about 45 minutes. Holy crap. This is indeed a most desirable outcome. That should allow me to be pretty active when we go to Italy in 6 weeks. But… “Can you also cut out my Bertolotti Deformity while you are in there? I’m pretty sure that is the cause of my disc herniation as it creates a rotational stress up my spine as it acts like a kickstand to L5/S1.”
The Bertolotti Deformity is a growth of bone off my L5 Transverse Process that extends down and connects to my Sacrum and Ilium on the Left (circled in blue). I’ve noticed for quite some time that rotating Left is just difficult for me. My side bending has not been symmetrical either. I attribute this to my inability to side bend Left at L5/S1 since that extra bit of bone acts like a kickstand to that motion. But since I can still rotate fully – that motion is just coming from the level above adding stress to my L4/5 disc.
The Bertolotti Deformity “isn’t an emergency” despite it contributing to increased stress at L4/5. We should just focus on removing the disc, in which, both neurosurgeons I consulted agreed on. But that would mean 2 recoveries… if I ever get around to an “optional” surgery…
Anyways back the the emergent situation…
The emergency of the herniation disc needing to come out right away (besides the worsening bilateral symptoms) comes from Ross’ sense of urgency of having to go to the bathroom. This is where some PT education could be lacking. We are taught to ask about a change of bowel or bladder function, but we are sometimes taught to just look for a “loss of control” of bowel and bladder. That and saddle anesthesia are called Cauda Equina Syndrome and indicate emergency surgery. And it is an emergency because those nerves are not as robust as the nerves descending down into your leg. They don’t come back if they are damaged. So unless I wanted to wear adult diapers for the rest of my life, surgery had to be done right away.
To clarify, the concern of Causa Equina Syndrome needs to be present with ANY change of sensation in bowel or bladder, just as Ross had experienced. That includes: a loss of control, a sense of urgency, even increased retention, and any change of sensation in the saddle region (numbness, tingling, tightness, etc.). Some of those symptoms may be confused with what someone would seek out pelvic floor rehab for, but our pelvic floor specialists are trained to differentiate between localized pelvic floor dysfunction, and that which is caused by spine cord compression.
After Ross’ appointment with neurosurgery, Ross just hung out in the emergency department, got his blood pressure taken and asked the same questions like, “When did you eat last?” ten times before rolling into the microdiscectomy.
While waiting, his doctor friend asked him if he had written anything funny on his butt. Oh man! I didn’t even think of that! But, if you, dear reader, ever have surgery where you will be face down with your tush exposed, be sure to write something funny on your butt. Or maybe just a simple “Thank You” would be appreciated as well.
Ross was wheeled into the room, and he saw the table he was going to lay on for the microdiscectomy. That looks super uncomfortable, and I wonder how are they going to get me up there? “Hey can you take pictures of all this for me? Or can I keep the disc that you take out? No? But I’m a PT and my wife works here as a PT too. I give you permission? Still No?” And then they put him to sleep.
Upon waking up after his Microdiscectomy
I saw the surgeon and gave him some knucks, because I felt gooood. Strength and sensation testing were fine, so the surgeon was happy. And then the surgeon let Ross’ wife know that the disc was a bit trickier to get out than he anticipated. My 45 minute microdiscectomy actually lasted one and a half hours.
Then Ross had to test out his Straight Leg Raise range of motion. Whoa. That improved from 30 to 45 degrees. That’s amazing.
And after getting up, walking, and wandering to the bathroom and back, he had to test out his calf strength. From 6 reps earlier in the day to 8 reps before loss of height on a rep. That’s incredible. And yeah, I noticed the recovery nurses shaking their heads at me. “Ugh… PTs…” I heard their judgey eyes say.
A 50% increase in range of motion and 33% increase in functional strength immediately after a microdiscectomy felt pretty amazing.
And if I had considered surgery sooner, maybe I would have been better off, sooner. But discs also heal.
I don’t know exactly why mine didn’t. I did the appropriate things and decreased load to my spine and kept moving. There were ups and downs in symptoms, and I found it interesting how suddenly things got worse after periods of feeling much better. I at least stayed strong and mobile up until the point where I absolutely needed a microdiscectomy. That should help recovery a ton.
Perhaps…
In one of my MRI reports, the radiologist reported that I had congenitally small pedicles which would decrease the size of my spinal canal. If my pedicles were a bit longer, they would increase the size of spinal canal, and there could be less impingement on the nerves. Maybe my body could have taken care of that disc fragment at that point and I wouldn’t have had the symptoms that I had.
I had also found that active spinal extension felt good and productive, but passive extension felt bad. Maybe if I was just stronger in my spinal extensors that would have helped? But bending forward and flexing my spine had always felt better for me (maybe because of the Bertolotti deformity). So working on extension never felt intuitive for me until it actually felt better (and I couldn’t passively flex my spine).
I didn’t want back surgery. But my outcomes have been pretty phenomenal.
Pain has been minimal and localized to the incision site (which is tiny). The only significant pain I had happened a week after surgery and was more due to a withdrawal from Celebrex. I stopped taking that to improve scar formation. Nerve symptoms have been absent in my left leg, and improving on my right steadily since surgery. Strength and activity tolerance is also improving as my nerves heal and disc scars down.
Ross attributed a few key things he did before his microdiscectomy to get the best outcomes:
- He found a Neurosurgeon to do spine surgery
- Our experience is that they have better outcomes than orthopedic spine surgeons
- He stayed strong
- Bed mobility and maintaining a neutral spine is much easier with a strong core and arms
- He stayed as active and mobile as possible
- Being bed ridden will make you weak and decreases blood flow
- If he had to unload his spine with crutches to walk more he would
- Maintaining hip flexibility would make moving easier with a straight spine
- He worked on spinal extension strength with isometrics
- This would help him the most to keep a neutral spine with activity
These are all things that would probably help most people before undergoing back surgery.
These are at least things to think about if you do absolutely need to a microdiscectomy or any other spine surgery. Starting PT before surgery can also help guide you through this process of building strength, improving mobility, and set your expectations before you undergo surgery.
Ross has a newfound perspective on sciatica, disc bulges, disc herniations, and when surgery is actually a better choice than rehab. So if you do have questions, please reach out to us to schedule an appointment. Or to get an answer to a simple question, feel free to email Ross directly at ross@altatherapies.com