NERVE REGENERATION PAIN in back with normal CAT, MRI scan.

Resolved Question:

I got a cat scan and a Mri and my doctor says the pain will go away in my back,saying it's nerve regeneration pain. The pain starts in my low back, in left glute, and down the outer quad, and front shin. I had a Tlif surgery witha PEEK interbody cage and mbp with bone allograft. I initially had leg pain in the front of the quad muscle that stopped at the knee as there was a cynovial cyst that encapsulated the L3 nerve and spondylylosis of the facet joint from previous discectomies. I am no expert but I was wondering what you see in these reports in laymans terms. The pain really started in month 3 and we are in month 5 and the pain is worse. Do you see anything my doctor is missing on these reports? I really need a doctor that specializes in this field for answers. This is my 3rd back surgery in the past year in the same area.


MRI SPINE LUMBAR WWO CONTRAST - Details
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About This Test

Details
Narrative
MRI of the lumbar spine with and without 7 cc of Gadavist

Technique: Unenhanced Sagittal STIR, sagittal and axial FSE T2.
Sagittal and axial T1 with/without gadolinium.

History: Status post L3-4 fusion for treatment of instability, a left
L3 pars fracture and a left-sided synovial cyst on April 9, 2015.

Comparison is made to the prior outside MRI of December 5, 2014 and
the x-rays of May 27, 2015.

There is a transitional lumbar vertebra. The most inferior disc,
labeled L5-S1, is rudimentary.

The vertebral bodies are normally aligned. There is no marrow
replacing process. The alteration of the marrow signal intensity at
the L3-4 endplates is secondary to postoperative change.

There is a small Schmorl's nodes at the superior endplate of L2.

The L1-2 disc is normal.

At L2-3, the disc has lost T2 signal intensity and height. The
annulus is bulging. There is a superimposed right foraminal disc
protrusion is associated with an annular fissure which mildly
encroaches upon the right neural foramen. The left neural foramen is
also narrowed by the bulging disc. These findings are unchanged.

At L3-4, there is a new left hemilaminectomy and facetectomy. An
interbody cage has been placed on the left side. There are also
bilateral pedicle screws. The central canal is patent. There is
enhancing granulation tissue in the left lateral and anterior
epidural spaces and throughout the left neural foramen. The central
canal and the right neural foramen are patent.

At L4-5, there is no change in the bulging disc. The right facet
joint is mildly degenerated.

No masses, signal abnormalities or abnormal enhancement is seen at
the conus medullaris which is located at T12-L1.

Impression: Transitional lumbar vertebra as detailed above.
1. Status post anterior and posterior fusion, the left
hemilaminectomy and left facetectomy at L3-4.
2. Enhancing granulation tissue in the left neural foramen and the
left anterior and left lateral epidural spaces at L3-4.
3. No change in the right foraminal disc protrusion at L2-3.

Component Results
There is no component information for this result.

General Information
Collected:
06/30/2015 9:02 AM
Resulted:
06/30/2015 10:39

Cat scan

History: 40-year-old male status post lumbar fusion. Back pain and left leg pain. Technique: A standard CT scan of the lumbar spine was performed without contrast. Multiplanar reconstructions were utilized. Findings: This study is compared to the previous MRI from 06/30/2015. There is a transitional lumbosacral segment labeled L5 on this exam which is
sacralized. There is a tiny L5-S1 disc. The same nomenclature utilized on the
previous MRI. The first nonrib-bearing segment is labeled L1.

Coronal scout images demonstrate very minimal dextroscoliosis of the lumbar
spine. There is minimal retrolisthesis at L4-L5. Vertebral body heights are
preserved. There is a prominent Schmorl's at the superior endplate of L2..
There is mild osteopenia. There is mild to moderate disc height loss from L2-L3
through L4-L5. There is been a previous anterior and posterior lumbar fusion
procedure performed at L3-L4. There are bilateral pedicle screws are parallel
connecting rods. The hardware creates metallic streak artifact limiting
evaluation of the adjacent structures. There is no evidence of hardware failure
or loosening. There is interbody fusion device within the L3-L4 interspace to
the left of midline. There has been a left hemilaminectomy at L3-L4 as well as
a left facetectomy.

T11-T12: Unremarkable.

T12-L1: Unremarkable.

L1-L2: Minimal generalized disc bulge. Minimal facet arthropathy.

L2-L3: There is a moderate generalized disc bulge. Right foraminal protrusion
is suggested. There is mild facet arthropathy. There is mild right greater than
left lateral recess narrowing. There appears to be mild left and moderate right
foraminal stenosis.

L3-L4: There is been a left facetectomy. There is some bone formation in the
left paracentral to left foraminal region along the path of the interbody
fusion device. There is been a left facetectomy. There is no central spinal
canal stenosis seen. There is moderate hypertrophic facet arthropathy. There is
some early changes of fusion across the right facet joint. There is mild right
foraminal narrowing. The left lateral recess may be significantly narrowed by
this new bone formation in the left paracentral to foraminal region.

L4-L5: There is a mild to moderate generalized disc bulge. There is mild
bilateral foraminal stenosis and mild to moderate facet arthropathy. There is a
midline fusion defect at L5.

L5-S1: The L5 vertebral body is sacralized.

Impression
Impression:
1. There is a transitional lumbosacral segment labeled L5 on this exam which
has been sacralized. The L5-S1 disc is hypoplastic. The first non-rib bearing
lumbar segment is labeled L1.
2. There is been a previous L3-L4 injury posterior lumbar spine fusion
procedure with left hemilaminectomy at L3-L4 as well as a left facetectomy.
There is no definite solid bone bridging across the interspace at this time.
There is no evidence of hardware loosening. 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. The position of interbody
fusion device does not appear significantly changed to intraoperative studies.


Category: Neurosurgeon

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Category: Spine Surgeon
Dr. Goutham Cugati is online now

Expert:  Dr. Goutham Cugati replied 4 Days.

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,


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.


Expert:  Dr. Goutham Cugati replied 3 Days.

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,


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.


Expert:  Dr. Goutham Cugati replied 2 Days.

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.


Dr. Goutham Cugati
Category: Spine Surgeon
Experience: 
Residency: Neurosurgery, the Post-Graduate Institute of Neurological Surgery, Dr. Achanta Lakshmipathi Neuro surgical Center, VHS Hospital, Chennai, 2011

Postgraduate in Neurosugery: DNB, National Board of Examinations,
Part 1 - 2008, Part 2 -  2010

Medical School: Bachelor of Medicine, Bachelor of Surgery, JSS Medical College, 2004
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