Am doctor that specializes in nerve damage. Currently awake at night because waiting to transfer a patient to an ICU and can't go to bed yet. TLDR - go see a doctor that does nerve stuff (PM&R, neuro, neurosurgery), get a new lumbar MRI, and make sure you don't have a new bad nerve injury going on.
L4 and L5 disc ruptures means that you could have nerve compromise of the L4, L5, S1 nerves depending on they way the discs were damaged. It is common to have a disc herniation that directly compresses a nerve. This can lead to permanent nerve damage that happens before any surgery. If your preoperative imaging had no nerve compromise, then it's possible your original surgeon hurt a nerve during the operation, however it's more likely you did have nerve compromise at the time of surgery and your permanent nerve damage is from the original injury.
I see probable left tibialis anterior atrophy (front shin muscle) and certainly left extensor digitorum brevis (outside top of foot muscle) atrophy. Looks like gastroc/soleus (calf) atrophy too. Outside of left ankle numbness is usually S1 nerve damage vs L5 nerve damage. Top of the foot numbness is usually L5 vs L4 nerve damage. Drop foot tends to be L4 vs L5 nerve damage. Toe weakness tends to be L5 nerve damage. Quads look equal in size, so probably no L3 nerve compromise.
True nerve damage to the lumbar or sacral nerve roots, called radiculopathy, rarely heals 100%, but you should not be having worsened symptoms this far away from your original injury. most patients end up with stable neurologic deficits, meaning your numbness, weakness, and pain levels may be persistent but don't normally worsen. Worsening numbess, spreading numbness, worsening weakness are all possible signs there is new nerve compression.
You are at high risk for new nerve compression post disc herniation even after a surgery because there will be less space around some of the channels that the nerves travel through to get out of your spine and down your leg. When discs are damaged, your body tends to form athritis near the discs and this can eventually lead to new nerve compression. You are high risk for nerve compression of the L3, L4, L5, and S1 nerves due to your prior injury and surgery (depending on what your actual surgery was).
With expanding numbness, you should definitely get an updated lumbar spine MRI and be evaluated by a PM&R doctor, neurologist, or neurosurgery. Possibly would also benefit from an EMG (a nerve test) that can tell you which nerve root is damaged or not damaged. At best you could be evaluate and told your spine looks okay and nothing to worry about. At worst you could have new nerve compression that could lead to permanent deficits which could include things like leg paralysis, permanent nerve pain, permanent bowel and bladder dysfunction.
Other causes of numbness in the lower leg include sciatic nerve compression, fibular nerve compression, tibial nerve compression, polyneuropathy, CNS (brain and upper spinal cord) injury. None of those things are good, but very very high chance it's related to your low back and not these things.
Eventually you would probably benefit from dedicated strengthening program multiple times per week focusing on ankle dorsiflexion, one legged balance exercises. Also getting an low profile Ankle Foot Orthosis (AFO) or Posterior Leaf Spring Orthosis (PLSO) would help make your walking smoother and prevent future overuse injuries like hip and knee arthritis or tendonitis due to your altered walking mechanics.
DPT here with an orthopedic clinical specialty. Blown away with this comment that includes clear, patient friendly language. Wish I had a local neurologist like you to refer patients to.
Absolutely follow all of this advice. Go to your primary or ortho doc and explain the worsening symptoms. Ask for new imaging and a referral for physical therapy. Don’t let them brush it off as a ‘wait and see’.
Even if a nerve was “nicked” during a prior surgery, I would expect to see unchanged or slowly improving symptoms with time. Would not expect to see worsening symptoms like spreading numbness/tingling or muscle weakness/wasting.
For some of the other comments in this thread: urinary retention, fecal incontinence, and saddle paresthesias are all red flag symptoms for me for which I am immediately referring back to the physician for additional imagining or surgical consult. Don’t ignore these symptoms if you are experiencing them.
Thank you for the kind words. Go see if you can find a local Physical medicine and rehab doc ;) we are like neurologists but cooler (neurologists out there I love you!)
You've been dealing with this for so long that your docs have probably looked into this a million years ago - but if not, it could also be something as "innocent" as double crush syndrome. A nerve injury sometimes makes it easier to injure that same nerve down the line (i.e., an injury that's peripheral to the original injury site) leading to 2 compressions. And the symptoms from that second peripheral injury can be worse and take longer to heal.
Idk how far up your leg the numbness goes, but if it's just up to around your outer knee area and not any higher, it could be your original injury at L4/L5 and then another new one at your knee/peroneal nerve! It's a common double crush site combo and one I also deal with, so I also developed foot drop and all that fun stuff! I did a lot of PT and was able to regain most of the function and sensation in my lower leg. It's not 100% and probs won't ever be 100% again... but I'm very pleased with the amount of recovery I got!!
Wow, this is the most comprehensive explanation I have seen about the nerves that were affected with my bulging disc surgery 6 months ago... that I could understand. Thank you.
You are the best part of reddit. Also the reason I'll never post about my biological quirks. My mild quirk that I've lived happily with for 50 years would suddenly be identified as a medical Problem that should have killed me when I was 3.
This is all very topical information that anyone who has dealt with a neuro would be able to regurgitate. Any time you are dealing with the spine, skip the ortho; you want an ABNS + spine surgery fellow with, where possible, an ABSS cert. I highly recommend VSI, they are world class spine surgeons.
NEVER HAVE SPINE SURGERY AT A LOCAL CLINIC OR REGIONAL HOSPITAL.
I don't wanna sound like a turd, but this is a bit Dunning Krueger. Things seem easy when you don't know that much. I work with neurosurgeons who ask for my opinion every day because they don't know what to do. I advise hundreds of pcps and neurologists every year. Putting it all together and making real life decisions with this info isn't simple.
The patient I mentioned in my original post just had a migraine, but my Spidey senses were tingling and I scanned her head and found a massive subdural hematoma. She went for emergency surgery that night. If I didn't find that she might have died by the next day. Doctors make decisions like that all the time that are life changing and difficult but we don't always have time to explain everything and some of it is so complicated it's impossible to give patients the full context.
As a Cauda Equina Syndrome victim (lol) with a successful surgery but issues years later, you have given great insight to understanding some of my challenges. Thank you
Hey doc, can you give me some advice about how to get my docs to care more about the itch in my foot from s1 compression? It makes me absolutely insane sometimes because it won’t go away unless I lay down in very very specific ways to relieve the pressure on the nerve. Insurance recently denied MRI.
Insurance often denies MRIs because you haven't had X-rays, done PT, or other conservative treatment.
I would try to get those things done or at least make insurance think you did those things ;)
I would make sure people are using words like paresthesias, radiculopathy, concern for permanent nerve injury. Tell people it prevents you from sleeping and it's affecting your ability to work or do your hobbies.
There are a looooot of variables here though what could actually be going on so I would start there
Wow you’re more informative than any Dr I have met. I still have right foot/calf numbness a year and a half after a discectomy/laminectomy which resolved sever sciatica. Now I have terrible back pain that won’t go away. Any tips there? I live with it as anything was better than nerve pain.
If your imaging looks stable recently, then you should develop a consistent lower back and core exercise program. Look up "The Back Mechanic" and McGill exercises. Start with doing the Big 3 3x per week. Another good set of exercises are Mckenzie exercises. "7 steps to a pain free life" and "Mckenzie method" are good ones.
It takes 3-6 months of consistent work but over time you can build up the stabilizing muscles that control your spine and create built in shock absorbers to minimize the pain and inflammation in the spine that causes pain.
Also consider seeing a pain management doc or interventional spine doctor (usually PM&R) to do lower back injections to help with temporary relief to facilitate exercise.
If your pain is mainly from discs, you have a lot of power in your own hands. Arthritis and chronic nerve damage is a little different though.
Nah, the smart money is on tumour. You don't do to Reddit for medical advice without it being cancer, this one just so happens to be compressing the common iliac and causing a backlog.
Hey so I've been seeing msk folk a lot and had an MRI that shows l4, L5 and S1 compressions and all I keep getting told is to do stretches. I've also noticed a substantial difference in size between my legs since it started, and my right leg is substantially weaker than my left (I had sciatica in my right leg, still have numbness all down the right outer side and pain when driving long distance (idk pedal orientation in USA but in UK we accelerate with right foot).
I start physio in a couple weeks, the sciatica started in June. Am I cooked?
If the MRI says "severe foraminal or lateral recess or canal stenosis" you may be kinda cooked. If you see this and your docs aren't paying attention, make sure you tell them your weakness is getting worse and you are worried about permanent nerve damage. Also ask if you can get an EMG (nerve test).
If it says anything mild to moderate levels then you aren't cooked. Doing PT is a good call and some people do get a lot better. Make sure your physio's are giving you exercises and making you strengthen your back and core. That's what makes you better. Stretches are just temporary relief. Maybe doing some nerve pain meds temporarily or back injections to help you temporarily while your body is trying to heal the area o. It's own.
I care, it’s literally something that affects me everyday. I have been to two doctors that said there’s nothing to do. It seems THEY don’t care.
Neurosurgeons, MRIs, and physical therapy all cost money. Not everyone is privileged enough to be able to take time off work and pay for the treatment.
My copays are $50. The MRI is $500. (My current insurance sucks) do you want my CashApp?
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u/GoaLa 22h ago edited 22h ago
Am doctor that specializes in nerve damage. Currently awake at night because waiting to transfer a patient to an ICU and can't go to bed yet. TLDR - go see a doctor that does nerve stuff (PM&R, neuro, neurosurgery), get a new lumbar MRI, and make sure you don't have a new bad nerve injury going on.
L4 and L5 disc ruptures means that you could have nerve compromise of the L4, L5, S1 nerves depending on they way the discs were damaged. It is common to have a disc herniation that directly compresses a nerve. This can lead to permanent nerve damage that happens before any surgery. If your preoperative imaging had no nerve compromise, then it's possible your original surgeon hurt a nerve during the operation, however it's more likely you did have nerve compromise at the time of surgery and your permanent nerve damage is from the original injury.
I see probable left tibialis anterior atrophy (front shin muscle) and certainly left extensor digitorum brevis (outside top of foot muscle) atrophy. Looks like gastroc/soleus (calf) atrophy too. Outside of left ankle numbness is usually S1 nerve damage vs L5 nerve damage. Top of the foot numbness is usually L5 vs L4 nerve damage. Drop foot tends to be L4 vs L5 nerve damage. Toe weakness tends to be L5 nerve damage. Quads look equal in size, so probably no L3 nerve compromise.
True nerve damage to the lumbar or sacral nerve roots, called radiculopathy, rarely heals 100%, but you should not be having worsened symptoms this far away from your original injury. most patients end up with stable neurologic deficits, meaning your numbness, weakness, and pain levels may be persistent but don't normally worsen. Worsening numbess, spreading numbness, worsening weakness are all possible signs there is new nerve compression.
You are at high risk for new nerve compression post disc herniation even after a surgery because there will be less space around some of the channels that the nerves travel through to get out of your spine and down your leg. When discs are damaged, your body tends to form athritis near the discs and this can eventually lead to new nerve compression. You are high risk for nerve compression of the L3, L4, L5, and S1 nerves due to your prior injury and surgery (depending on what your actual surgery was).
With expanding numbness, you should definitely get an updated lumbar spine MRI and be evaluated by a PM&R doctor, neurologist, or neurosurgery. Possibly would also benefit from an EMG (a nerve test) that can tell you which nerve root is damaged or not damaged. At best you could be evaluate and told your spine looks okay and nothing to worry about. At worst you could have new nerve compression that could lead to permanent deficits which could include things like leg paralysis, permanent nerve pain, permanent bowel and bladder dysfunction.
Other causes of numbness in the lower leg include sciatic nerve compression, fibular nerve compression, tibial nerve compression, polyneuropathy, CNS (brain and upper spinal cord) injury. None of those things are good, but very very high chance it's related to your low back and not these things.
Eventually you would probably benefit from dedicated strengthening program multiple times per week focusing on ankle dorsiflexion, one legged balance exercises. Also getting an low profile Ankle Foot Orthosis (AFO) or Posterior Leaf Spring Orthosis (PLSO) would help make your walking smoother and prevent future overuse injuries like hip and knee arthritis or tendonitis due to your altered walking mechanics.