Test Results from MRI and EMG/NCV

After being down and out from being sick, I'm finally back to feeling like my old self. :) During my absence, I had a couple more tests done. I actually had two MRIs done as well as an EMG with a NCV. I ended up having to have two MRIs done simply because the first was done without contrast. The results of those test are as follows:

MRI # 1

FINDINGS: There is normal alignment of the lumbar spine. No marrow signal abnormalities are seen. The spinal cord is normal in signal and terminates appropriately at L1. The paraspinal soft tissues are   unremarkable. Lumbar fusion hardware is seen at L4-5 and L5-S1. Local susceptibility artifact limits revaluation of these disc levels. There apprears to be soft tissue in the ventral epidural space at L5-S1 which could be susceptibility artifact or soft tissue. If soft tissue, this may represent residual/recurrent disc herniation versus scar. There is effacement of the ventral space but no significant central stenosis is seen. There is mild bilateral facet osteoarthropathy.

    
IMPRESSION: Status post lumbar fusion L4-5 and L5-S1 with susceptibility artifact from the fusion material which somewhat limits evaluation of the L4-5 and L5-S1 as described above. Soft tissue of the ventral epidural space at L5-S1 could represent residual/recurrent disc herniation versus scar tissue but assessment limited by adjacent susceptibility artifact.

MRI # 2

FINDINGS: There is enhancing epidural tissue at the L4-5 and L5-S1 post discectomy interspaces that
is not exerting any mass effect and some of this is surrounding the right L5 and S1 nerve roots in their respective lateral recesses. The granulation tissue, slightly enhancing, at the site of the previous L5-S1 disc protrusion is unchanged from the recent study and smaller than it was on 6/2012. This is the only area where there is any mass effect. There is no evidence of disc space infection although that is somewhat compromised by the metallic artifact from the intervertebral spacers.  All of the higher lumbar intervals remain unremarkable. No new or different pathology compared to the recent exam. The intervertabral spacers are new compared to 6/2012.

IMPRESSION:

1. Stable or slightly decreasing regions of enhancing epidural soft tissue L4-5 and L5-S1.
2. No new or different pathology compared to the recent study on 02/2013.

EMG/NCV Study

     Summary/Interpretation:

1. The only abnormalities of this study were the absent right and prolonged left H-reflex consistent with chronic S1 radiculopathies.
2. On clinical grounds a mild residual right L5 radiculopathy is suspected.
3. Importantly there was no electrodiagnostic evidence for an acute/ongoing right lumbosacral radiculopathy at this time.

Basically, the neurologist believes the radiculopathy I am experiencing is a result of scar tissue. I inquired about getting a CT myelogram and he advised against it because it is invasive. He believes the pain I have now will subside with time. On the other hand, my orthopedic surgeon wants me to go ahead and get the CT myelogram because the MRI results are inconclusive. Personally, I'd like to know why I'm still experiencing pain in my right leg. So I have decided to get further testing done. I'm scheduled to have the CT myelogram in a couple of weeks. Hopefully, that test will provide some much needed answers.

 

Residual Nerve Pain

It's been 5 months post surgery and I have some lingering residual nerve pain.  I have pain in my sciatic nerves and the anterior tibia muscle that is isolated in my right lower extremity. The pain level is manageable with the NSAID I'm currently taking. It does get aggravated the longer I sit. After about two hours of sitting, the pain becomes more intense and it's coupled with numbness. Since the pain has not completely subsided Dr. Clavel has ordered more testing. On Friday, I'll be going in for another lumbar spine MRI to rule out any nerve compression. At the end of the month, I will be going in for a Nerve Conduction test along with an EMG. 

On another note, my lower back feels great. I have absolutely no pain in that region; it feels much stronger than it has ever been. As far as the scar on my abdominal goes, I think it looks slightly better than before. I went from using Mederma to coconut oil and now Vitamin E oil. The scar itself (in texture) has completely flattened out. It is hard to the touch, and there is absolutely no sensation to the bottom half of the scar. I think the appearance of it is the best it's going to get.

On My Own

A couple of weeks ago I had another reevaluation at Active Physical Therapy. Here's the latest assessment:

Active Range of Motion (AROM):

• Flexion - 64°
• Extension - 17° 
• RSB - 30°
• LSB - 35°

Manual Muscle Testing (MMT):

• Core - 4+/5
• Hip - 5/5
• Knee - 5/5

Other Tests/Measures

• Straight Leg Raise (SLR) - both at 88° 
• Sit and Reach to Anterior Ankle
• Numbness and Tingling to right lateral shank intermittently

According to the physical therapist, I had reached my maximum potential and was finally discharged. I had been going to PT since late February to late December. After several months of going to PT, it feels strangely odd to not have to go for my weekly workouts. Since I've been discharged I haven't kept up with my exercises. I know, it's terrible! Once the weather clears up a bit around here I will get back in to my old routine of going for a walk at least three times a week. As for now, the residual pain I have is minimal and definitely manageable. I am in the process of weaning myself from the two medications I'm currently taking: Neurontin and Meloxicam. After about two weeks, I should be completely medication-free.

On another note, I finally received a response from Yolanda. It turns out they were in the process of moving office locations. Hence, the delay in her response to my emails. Unfortunately, Dr. Clavel has not been able to give me any feedback on my last x-ray results. I'm hoping within the next week or so he'll have time to review everything and provide some answers to questions I had brought to Yolanda's attention.

X-Rays taken at the Three-Month Mark

Sorry, I've been slacking with this blog.... It's been exactly 4 months since I had the 2-level ADR surgery. I had x-rays taken last month on 11/28/12 and had sent them in for review, but I have yet to hear from Dr. Clavel. I had hoped to hear from him by now considering it's never taken this long to get a response. I'm assuming it's because of the holiday season.... Anyways, I had the x-rays taken at my orthopedic surgeon's office. Dr. Asdourian said the images looked great; the implants are settling in nicely with the vertebrae. Of course that was great news. The only thing I'm slightly concerned about is the fact that I've been having constant pain in the anterior tibia muscle. This has been going on for the past 2 months now. Dr. Asdourian is not quite sure why I'm experiencing pain in that part of the leg. He gave me a plethora of reasons from scar tissue to possibly a pinched nerve, etc. He wants me to get either a MRI or a CAT scan (it depends on Dr. Clavel's recommendation) just to make sure a nerve isn't pinched. In the meantime, he prescribed Neurontin and Meloxicam in hopes it will help alleviate the pain.

Frontal View

Lateral View

Once I hear back from Dr. Clavel, I'll post an update. Thus far, I've been doing relatively well aside from the pain. I have already gone back to work full-time and have been driving around without any issues (yes, I still wear my back brace for safety precautions). I've regained most of my strength and flexibility...thanks to my awesome little family at Active Physical Therapy. (Tomorrow I'll be going in for another reevaluation so there is a good possibility my PT sessions will be coming to an end). I'm not as ecstatic as I thought I would be for hitting this milestone...perhaps my celebration will happen once I hear back from Dr. Clavel and get the reassurance I need that everything is going as well as expected.

12th week Physiotherapy Reevaluation

My physiotherapist did another evaluation. From his standpoint, I'm well on track with my range of motion. His assessment is as follows:

• Flexion - 51°
• Right Side-Bending (RSB) - 30°
• Left Side-Bending (LSB) - 32°
• Core Strength - 4/5
• Hip Flex/Abduction - 4+/5
• Straight Leg Raise: Right - 87°, Left - 86°
• Sit and Reach to Ankle

According to his assessment, I have improved in all areas. After I voiced my unrealistic expectations of wanting to attain the same level of flexibility prior to surgery, he recommended another 4 weeks of therapy. Thus, I am still going 3 days a week. There has been a slight change in my workout routine. All the weights I've been working with have increased by one pound. Additionally, two exercises have been incorporated to work on my core strength: walk-out and push-ups on the medicine ball, and walk-out with leg raise, again on the medicine ball.

Wicked Scar

It's been exactly 10 weeks post surgery. The scar still looks pretty wicked even though I've been using Mederma (gel applied topically to diminish the appearance of scars). Most of the swelling has gone down around the incision. To the touch, there are certain areas along the scar that is completely numb and you can definitely feel the scar tissue. I believe there is some permanent nerve damage along the incision. It has been more than 2 months and the sensation has yet to return. Oh well. The scar looks unsightly for sure, but on the upside the pain and itching subsided. Here's what it looks like:

Wicked Scar

8th Week of Physiotherapy

This week marks the 8th week of physiotherapy here in the states. And yes, I'm still going 3 days a week. Since my last reevaluation not much has changed. At least from my standpoint. My range of motion feels about the same, but I will know for sure when I go in for another evaluation. The only thing that has changed since then is my workout routine. Weights have been incorporated to build up the strength in my legs and my abdominal muscles.

Here's my current workout routine:

• 10 minutes (3.3 miles) on the recumbent exercise bike 
• 3 sets of sidesteps with green resistant bands around ankles = 60 sidesteps
• 20 squats on bosu ball with 2 lbs weights in each hand
• 40 repetitions of alternating leg and arm lifts on medicine ball using 2 lbs weights on each ankle and 2 lbs weights in each hand
• 40 pelvic tilts on medicine ball simultaneously with bicep curls - 4 lbs dumbbells for each hand
• 2 sets of 10 for three-way leg lifts with 4lb ankle weights
• 20 reverse crunches with ball
• 40 (20 for each side) upper body rotation using red resistant bands 
• 10 cat and camel stretch
• 3 sets of hamstring stretches for both legs (30 secs per stretch) 
• manual stretch for hamstrings by the therapist

My current routine lasts about one hour. I opted out for the heat and electro stimulation simply because I've never felt any relief from it. In my personal opinion it was just a waste of time.

I do feel much better as a result of the surgery, but want to emphasize the point that I am not 100% pain free. I still have lots of pain in my sciatic nerves, glutes, and in my calf. With the exception of the glutes, the pain seems to be isolated primarily in the right leg. I have absolutely no idea why that is, but I've already come to terms that the existing pain will most likely last forever. It's not a shooting pain, but more so a throbbing pain in isolated areas. Now it's not constant, it is intermittent which is something I can deal with.

Tomorrow I will post a picture of the scar. :) For any of you whom are interested in getting an artificial disc surgery please feel free to ask any questions you may have (either about the surgery and/or recovery, about Dr. Pablo Clavel, Barcelona Spine Center at Quiron Hospital, or about Stenum Hospital).