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My husband had a herniation at L2-L3 two years ago: left quad atrophy, left quad weakness, left shin sensory deficit, etc. He had decompression surgery 20 months ago and has since had several rounds of physical therapy and follows a daily exercise program. He has used a neuromuscular stimulator on the quad as well. Although quad atrophy (VMO) is still obvious, a recent visit with a neurologist at Mount Sinai in NYC found some nerve damage, "not very significant", and his strength was rated 3+, maybe 4. The doctor said the atrophy is representative of his quad strength. However, my husband says the quad feels "weak" and there is also a "pulling" feeling when he walks.

Here is the problem. Shortly after the herniation and muscle atrophy, my husband developed knee pain in the affected leg. This has been progressive over the last 18 months and now he has bone on bone knee osteoarthritis. The orthopedists have him slated for a knee replacement but my husband and I wonder how can he have a successful knee replacement if there is already weakness in the quad as a result of nerve damage. We have no doubt that the knee problem developed from the quad weakness/nerve damage. The doctors don't seem to really address this and say he will just have to work very hard in rehab after the knee replacement, and "we replace the knees of polio patients."

Is there any chance this nerve damage will still improve after 20 months? Can he strengthen this quad further and hopefully improve this knee condition and avoid the knee replacement? My husband is pretty well convinced that if he has the surgery he will wind up worse than he is now. He feels that he is in a class by himself because it is almost impossible to find stories of other people who have had herniations at L2-L3. Please advise.

Category: Orthopedic Surgeon

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Category: Spine Surgeon
 20 Doctors Online

Welcome at Doctor Spring.

I have read your question with diligence.

If his osteoarthritis is of grade 4 or severe damage is there in his knee then for relief of pain he may have replacement surgery. But this procedure is not indicated with sever quadriceps weakness.

The tricky part here is whether your husband has a significant quadriceps weakness. From whatever information you have give me, it does not seem that there is significant weakness.

Another fact here is that the knee osteoarthritis is NOT directly related to the nerve injury. The inactivity might have triggered it, but one is nerve injury and other is joint problem. So it is not correct to assume that the knee pain is from the disc prolapse. As you would have already realised that a complete muscle strength is not required for normal day to day functioning. But an additional knee arthritis with the the quad weakness could really disable him.

So the things to consider are :

1.The Quad weakness and the knee pain are both different problems and hence it has to be address separately.
2. In an individual with severe Quad weakness there a knee replacement might be beneficial (except for the pain management ). But in a individual with a functioning but weak Qauds it certainly can help .

The final decision has to be taken by you in consult with your Doctor, since this is an elective procedure. Do discuss these concerns with your Doctors also. In my opinion you can try non surgical option for few more months or so and re asses . But I would recommend to you be to open to this option. I don't see any reason why it should worsen / complicate the existing scenario.

Hope this will help you.
Feel free to ask followups / clarifications.
Thank you

With inputs from Dr.Deepu Sebin Sebastian

Patient replied :

Your answer was most helpful and I appreciate the fact that you were able to zero in on the issues and our concerns. Every doctor we have seen feels the quad weakness is NOT severe. Last question: it has been twenty months since my husband's decompression surgery at L2-L3. What are the chances for further improvement of residual nerve damage and what can he do to improve?
Thank you so much!

The chance for the already damaged nerve to recover/ improve is bleak. This mostly would be permanent damage. So the the important thing here is to keep up with the Physiotherapy and active mobilisation.

If he uses that limb less (because of the weakness or pain) the Quads will undergo atrophy. And because of this atrophy the use will again decrease - a vicious cycle will set in. So it is very important to keep it moving. This preserves the remaining nerves also.

That is why addressing the knee pain is important. Any disuse because of the pain should be avoided. So gain keep a very open mind about the Surgery. There is no need to hurry into it, but do not dismiss it thinking that it will complicate.

Hope this helps
Feel free to ask followups
Thank you

Dr. Mukesh Tiwari
Category: Spine Surgeon
Fellowship - Khandaka Hospital, Jaipur
Residency - MS, Rabindranath Tagore Medical College, Udaipur, 2000
Medical School, Internship - MBBS, SMS Medical College, Jaipur, 1995
Dr. Mukesh Tiwari and 4 other Medical Specialists are ready to help you

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