Slipped (Herniated) Disc -- Surgery?

[david_je]

Hi,

I'm 55 and have had chronic lower back pains of a pressing type for years. Since last November, I have had moderate, sharp pains in lower back and upper buttocks and some numbness and tingling in my lower left leg and foot.

I saw Dr. Wicharn at BNH (recommended in this forum). MRI showed slipped disc at L4-5 and L5-S1. Two weeks of pelvic stretch PT, a short course of Prednisone, and a month of Arcoxia, Lyrica and B-12 have eased the pain only slightly (for whatever reason, the pain's only navigated from the left to the right side). The past week, I started doing back strengthening exercises. Dr. Wicharn believes I should consider surgery ("keyhole microdecompression"). I'd prefer not to have surgery. I have read that often, slipped discs resolve by themselves over time -- but also that some people do need the surgery. So I have to decide how long I can wait.

I'd like to hear from anyone else who has been in this position.

And anyone who had such surgery in Bangkok, with Dr. Wicharn or whoever, and what the experience was like.

Thank you.

[Sheryl]

The herniated ("slipped") disk will indeed resolve over time. The question is:

- whether you are prepared to live with the pain in the meantime (only you can answer that)

and

- what degree of spinal stenosis is also present, which is turn predicts how pain free you are likely to be when the herniation of the disk subsides. Spinal stenosis = narrowing of the space where nerves exit the spinal column. When herniated disks resolve they often do so in a compressed form which will further reduce the amount of space. Depending on how much space remains -- and also on whether there are any bone spurs pressing on the nerve -- even after the herniation resolves you may still have pain. Not necessarily, but can be. An experienced spinal surgeon can generally predict this,

In cases where the pain is radiating to the leg/foot, there is compression of the nerve root. It is not advisable to leave that for too long as nerve damage may result. usually if the pain is going to resolve with conservative measures, it will do so within 6 -12 weeks. From what you say it has been only 2 weeks. You could give it another month or so provided (1) the nerve root compression is not putting you ate risk of permanent nerve damage/impairment - if you are able to walk normally now (albeit with pain) it probably isn't, but if you are limping or experiencing a loss of motor strength in the leg or foot this may be a concern. (2) the degree of spinal stenosis is not such that even once the disk retracts you will likely have some nerve impingement and hence pain.

Discuss these points with Dr., Wicharn. Ask him specifically what he thinks the odds are (1) that once the disk has retracted, you will be pain free and (2) that waiting till then may cause some permanant nerve impairment, i.e. an you safely wait another month.

Over the years I have referred many people to Dr, Wicharn and he operated on my sister twice (once lumbar, once cervical spine -- great results both times). I have found his recommendations to be spot on and also that he will not suggest surgery if it is not indicated. I plan to consult him shortly myself for possible surgery on the cervical spine if the %^$# pain I am in doesn't soon resolve...

If you are going to have the surgery do not wait more than 3 months maximum, the procedure is less effective by that point. And be mindful of the risk of nerve injury. My brother delayed his surgery too long, ended up having to have a fusion and while it was totally successful in reliving his pain he was left with a residual limp from nerve damage already accrued from prolonged pressure on the nerve root.

some good references

http://www.ncbi.nlm.nih.gov/pubmed/15744701

http://www.spine-health.com/treatment/back-surgery/microdiscectomy-microdecompression-spine-surgery

[david_je]

Thank you, Sheryl, for your very helpful comments.

I saw Dr. Wicharn again last week. He said I am a good candidate for the surgery, that it would make me better a lot faster. He also said there's a chance the herniation could worsen, and may require, just as you mentioned, more complicated surgery later. I told him of my reservations about surgery (risks, possibly no need, etc.). He said you shouldn't wait long for surgery if the symptoms are getting worse or not getting better, but that you can wait to make a decision if they were stable or improving-- the additional time would not affect the efficacy of the operation.

Well, since my symptoms started last November, I've had sharp pains mostly in upper buttocks and general band of stiffness-achiness around waist, but no leg pains, numbness, loss of mobility, etc. And in past couple of weeks, most of the sharp pains have eased. I know the vast majority of herniation cases resolve themselves, and long-term, there's little difference between those who have surgery and those who do not. One main concern I had was whether I could return to vigorous exercise including jogging without fear of worsening the back if I did not have the surgery and it resolved by itself -- and Dr. Wicharn said I could.

So I am inclined to wait, while taking Vit-B complex, Lyrica 75mg daily, and exercising back. What do you think? And do you think I should spend the money to get a second opinion, and if so, from whom?

Thank you

[Sheryl]

I would take the advice of the specialist who has seen your test results. I am not totally clear from what you say what that was i.e. if he thinks the pain will fully resolve with time or if there is too little space for the nerves. The herniation of the disk will resolve but any narrowing of the space where nerves exit the spinal column will not, in fact it may worsen.

You can certainly get an other opinion but in my experience Thai doctors have a tendency to disregard history and treat each patient contact as if it were the first time the patient had been seen by anyone. In which case they will tell you (1) to try 1-3 weeks of conservative treatment first and (2)(consider surgery only if that doesn't work.

However to my understanding it has already been at least 4 months. So I am not sure how much of your pain is due to the disk herniation vs narrowing of the nerve outlet. From what you say the doctor has said, it may be the latter, but my trying to infer fro what you said he said is like a game of "telephone".

By all means go ahead and try to get another opinion, bringing all records with you but don't be surprised if the doctor gives you the standard "try conservative measures first" speech even though you have already done that. They tend to give weight only to what their own records prove has transpired, and hesitate to recommend surgery the first time they see you but rather want the documentation of having first prescribed all the things you have already done.

In terms of whom to seek anothter opinion from, this doc at Bumrungrad looks very well qualified but I have no personal expereince with him:

http://www.bumrungrad.com/doctors/Areesak-Chotivichit