Dinhofer's Spinal Surgery (Discectomy) Thread

scott dinhofer · September 4, 2015 1:52PM

As many of you know I suffered from a herniated disc in Lake Placid, three days before the Ironman. Since then I have been able to swim (limited by my rotator cuff surgery last December), started on the bike again, no significant issues, unless I am climbing out of the saddle. This week I tried running - major fail.

Symptoms - numbness in left lower leg, weakness in upper inner thigh (as in muscles not firing)

Prescriptions - was sent to see the surgeon by my physiatrist, not out of my own desire to push treatment further.

The surgeon's assessment is that if i do nothing, there is a high probability that have a mostly full recovery in 6-8 months. Meaning, that it will be that long before I can begin to make a real training effort. It may also be the earliest that my nerves begin to heal and i can start...

his further assessment is that if I have the surgery, the nerves begin to heal now, I am back on a bike trainer in 2 weeks (at Z2) and swimming thereabouts as well.

Risks - the surgery is not near the spinal cord, so that is not an issue, the only real one is that they damage the nerve during the surgery, unless i am missing something. so, please chime in!

Chris Ciannella · September 4, 2015 3:15PM

I'm not a doctor, but I did sleep at a holiday inn last night! Seriously, I go to a chiropractor and he basically saved me from having back surgery and enabled me to get back into doing tri's - I was out 2 years trying to figure this out. You can also go to physical therapy where they will probably put you on a machine that decompresses your back - this didn't work for me, but its an option. You may also want to get a steroid shot to help alleviate the pain, but this is only a short-term solution and will not help with your underlying issue. I would exhaust all options before having surgery. If you have to sit out a season, so be it - just my 2-cents though

Good luck man

Douglas Sutherland · September 4, 2015 11:15PM

So, full disclosure, I am a surgeon. But not backs. My experience includes a wife who had a microdiscectomy and just recently a very close friend. My two cents: This is a very minor surgery, I consider this more of a "procedure". Nothing like a fusion. Incision is about 2 inches longitudinally in the small of your back, go home same day. Risk is low of a nerve or spinal cord injury. I have never felt surgical pain myself, but my perception is that it is very doable, often done on rather elderly and sickly people (which speaks to the tolerability of the case, not you

As for results, my wife is truly a different person for it. She was really unable to be active in any way despite the whole 9 yards of alternatives. Following surgery, after ramping up for 3 years became a competitive figure model. Now she is a newbie triathlete. No way she could have done that without surgery.

I agree, all options should be exhausted before surgery. This is intuitive. However, we should not expect major results with half measures for big problems. A disk that is protruding onto a nerve doesn't every really "go back" to normal. After 8 months of conservative measures, you might find out that you still can't move much.

DS

steve Beyer · September 5, 2015 5:57AM

So like Doug I'll give full disclosure, I'm a chiropractor. Agree with what Doug said about the discectomy being a minor surgery, so as far as a surgical approach to the problem, I think it's the way to go.

Of course I definitely agree with exhausting all conservative options beforehand, even if the surgery is "minor". I say this first and foremost because of how I view the big picture of disc problems.....which is that a bulging disc is bulging because some of the "annular" fibers have tore, which happens at least in part because of poor joint biomechanics of the vertebral segments above and/or below the offending disc. This is why I've seen a lot of people over the years who have previously had discectomies....ie..the discectomy didn't address the joint bio mechanical issue at all.

So sometimes a conservative approach can save you from surgery, but sometimes surgery is the only thing that will truly get the bulge off of the nerve root(and thank goodness there are those skilled surgeons out there in that case!). But even when that's the case, there should be some type of approach (chiropractic, decompression therapy, PT, combo of those), to address the underlying faulty joint biomechanics.

That's my .02, good luck with whatever you decide.

scott dinhofer · September 5, 2015 6:00AM

@Doug (and others)

yes, this would be a microdiscectomy.

of the three people with knowledge, all of had said after looking at my MRI something like that is a "significant" herniation. Prior to getting a Epidural Steroid Injection (ESI), I was in extreme pain. I have been essentially pain free since then and only now have some very mild pain developing. That could come back. Which would argue for the procedure as another shot would just be a "band aid."

I believe in the exhaust all options methodology, as does my chiropractor

Chiro feels that this will get smaller over time (white blood cells, etc) his belief is that most of us have herniations and walk around with them every day. It's the ones that hit a nerve that are bad. So, I probably had a herniation before (can guarantee it) and it only got bad for whatever reason, in July, 3 days before LP. That it doesn't need to recede all the way on its own, only partially.

His argument is that if I continue to do essentially his PT work (core, upper body strengthening, swimming, and lighter, flatter moderate biking) I will probably be good to go in January, no guarantees.

IF i do the microdiscectomy, it gets done in a week and a half, 2 weeks of no exercise, then a very slow build up of activities. Probably in the same place as Chiro predicts. Issue is that if Chiro isn't right, I could be looking at the Microdiscectomy in January and then next year IS lost...

While I get this is a game, it IS a lifestyle, I lost a full year with an incorrect Cardiac diagnosis in July '12, so I am sort of fresh out of the "lost a year" scenario...

I guess what I am looking for here, is someone to say, this IS a procedure, it is the best way to get going again, just swallow it and get it done...

Douglas Sutherland · September 5, 2015 8:25AM

I am not a spine surgeon, but this IS a procedure. We do far more damage in bigger surgeries. But... even small procedures carry some risk. I would simply say this is a small risk procedure.

A few more points I should note about my wife. Like you, she did have a significant protrusion with nerve compression (due to face planting while waterskiing in 2004ish), and we were able to get her consistently to a place of being painless with conservative measures. She did a lot of chiro, injections, bought a new bed, fancy chair. She comes from a competitive basketball background. Docs/chiro slowed her down to walking and watered down kickboxing/aerobics. While she was active, but she was not active to the point she wanted to be, and this would lead to a cycle of doing ok, then push it, then back pain comes back, then back to rehab, etc, etc. Also, the pregnancies added pain, not relevant to you. This cycle occurred for about 6 years, which is how long she successfully avoided surgery. It was at the beginning of a cycle of pain that she gave in.

Following surgery she still does all of the same stuff - chiro, fancy bed, chair, foam rolls, etc. But now her level of activity is substantially higher - she is a cross fitter type with emphasis on olympic lifts and she is stoopid strong, so is lifting heaving weight. She still has some back pain rarely, but this pain is nil, manageable, and again, radically different.

I should state triathlon training, the increased running specifically, has caused her hip pain. It turns out she has foot drop from the chronicity of the compressed nerve, this has screwed up her gait some. This is very minor, not noticeable, except when she started to run for 45 min or longer. Doc, chiro, PT all agree this problem happened because of the delay to definitive therapy. It will not stop her, but her gait is probably permanently altered.

So, from my perspective, the decision comes down to how active a person wants to be with this issue. If you can tolerate mini-moderate activity and not experiencing any major nerve injuries, avoid surgery. If you want to be very active, I say surgery.

As I recall, this happened to you while you were sleeping in a new bed at LP, right? Was there big activity before that? If sleeping on a new mattress caused this, well, that would be a very minor trigger suggesting your protrusion is pretty labile. Hard to image being conservative if that is all that got you here.

DS

rlh2000 · September 5, 2015 9:44AM

Whether or not you do surgery, very important to address posture, core weakness, etc. surgery fixes the problem but not the cause of it. I have seen a lot of folks coming into therapy several years after a microdiscectomy with a return of symptoms.

scott dinhofer · September 5, 2015 3:17PM

the bed, was probably a small player. I am now fully convinced that this herniation happened a long time ago and that a combination of a bad bed, lifting 2 bikes on and off the car roof rack 6x (to ride the LP descent) and stretching my back while leaning over a picket fence, really caused the final bad herniation. I actually had some twinges in the back before I left for LP and had thought about getting to see Chiro before I left. I have had an ongoing SI issue from a fall down a few stairs around 3 years ago.

here is where I AM able to ride, probably have a 10watt drop since LP, but executing flatish rides around here at .7IF(based on LP FTP) did this crazy climbing ride last Friday - was no worse for wear - https://www.strava.com/activities/379454748
I am able to swim
I am NOT able to run, nerve damage from this is preventing me to use my leg correctly for running and for out of the saddle climbing on the bike.
I am mostly pain free from the ESI, g-d knows how long that lasts.. and if it doesn't, i will be screaming for this procedure. some pain has returned recently and I don't know if that is a result of the biking I am doing or the ESI wearing off, or both

Would I say that I have exhausted the non-surgery option? NO, I think I could only say that if come January, the Herniation hasn't receded enough to allow me to start running again. @Doug - totally identify with the gait issues you mentioned, as I have no ability to run right now.

As an aside, curious as to our thoughts on this: a good friend who is a doc, not a surgeon or a spine doc, basically felt that no DOc worth their salt would operate on me until I waited it out longer and took the exhaust all options route...

I have neglected core for years, so now i have a 45 degree bench, and am doing daily back extensions, planks, side planks, cable rows, wood chucks, and pulldowns... no longer taking that for granted.

Paul Hough · September 5, 2015 3:40PM

Good luck on whatever you decide Scott. You have some outstanding advice above. I just want to add that this shows how right you were to take a pass on IMLP this summer.

robin sarner · September 6, 2015 1:18PM

message Robert sabo. he is neurosurgeon.

Douglas Sutherland · September 6, 2015 5:45PM

Dr. Sabo can get more specific on this, but re: "...no DOc worth their salt would operate on me until I waited it out longer and took the exhaust all options route..."

This is the 'popular' sentiment out there amongst all it seems. Needless to say, try not to take a one size fits all approach to this decision. It is truly never wrong to wait longer and allow for conservative healing. And this sport is certainly a hobby for all of us, so none lose a paycheck for being injured. But there is a cost associated with the decision to observe, and trust me, I have heard too many people say "why did I wait so long, I was miserable..." after deciding to wait longer. There is a time and a place for early surgery and very athletic people are that time and place, in general. Why? Because, you are a better protoplasm than 95% of the people out there needing the procedure. You will honor your end of the bargain - arrive to surgery without being an obese, smoking, narc'ed up prospect, go to PT like you are told to, probably do extra PT within the limits you are told, not hog out and gain 25lbs while recovering, etc, etc. That is not the case for the vast majority of people. The risk of the surgery is low, as I said, but the risk of having the surgery is particular lower because of the person you already are.

This is not a commercial for surgery, mind you, just food for thought. Everybody needs to make their own decision.

DS

Robert Sabo · September 22, 2015 1:37PM

I am a Neurosurgeon who specializes in Spine surgery. I will try to simplify the general algorithm for Lumbar radiculopathy(sciatica). When a patient has low back pain with or without sciatica they will usually get better within the first 6 weeks no matter what treatment. Therefore we try to avoid lumbar microdiscectomy until at least 6 weeks of non-surgical therapy; PT, Chiro, pain management injections. UNLESS there are "red flags" such as weakness, usually a foot drop, or if there is bowel or bladder incontinence (aka Cauda Equina syndrome which is a surgical emergency) then we would recommend surgery sooner.
I have seen foot drops improve with time without surgery and I have seen weakness remain despite MRI showing resolution of the disc spontaneously many months to year(s) later. I go by the severity of weakness and with the course of whether it is improving or worsening over time. ie if the weakness is getting worse over a few weeks, I would lean towards surgery. Pain is only a factor of what the patient could tolerate. I hope some of these generalities are helpful. Obviously the physical exam by a neurosurgeon and evaluation of the MRI would be imperative prior to making a educated recommendation. Issues on exam, patient's specific complaints, and MRI findings will determine suitability for surgery, microdiscectomy or possible fusion, or no surgery.

Dinhofer's Spinal Surgery (Discectomy) Thread

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