oreosandsake

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I have a 30 y/o physician colleague with unilateral L5, and S1 radiculopathy. He has had 2 level microdiscectomy in the past -- L4-5-S1, approx 5 years ago. he still has foraminal stenosis, and also has central canal stenosis.

the symptoms have recently returned. although they have a fluctuating grade in severity.

He is looking for the most conservative treatment. He is NOT looking for lami with fusion and hardware.

Can someone comment on the outcomes for foraminotomy? is it common for these to be performed at multiple levels?

would appreciate any help. Thank you
 

Taus

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Not directly answering your question... but...

You're a smart dude.... so I'm sure he's already done appropriate PT, meds, esi, etc

Has there been a new MRI w/ gad?- ie any signif scar tissue encasing nerve roots?
Foraminal stenosis from what? New recurrent disc or combination of factors w/ bone? Lateral recess involved? Would expect L4 and 5 roots (not 5/1) involved if solely foraminal stenosis
 
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oreosandsake

oreosandsake

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Not directly answering your question... but...

You're a smart dude.... so I'm sure he's already done appropriate PT, meds, esi, etc

Has there been a new MRI w/ gad?- ie any signif scar tissue encasing nerve roots?
Foraminal stenosis from what? New recurrent disc or combination of factors w/ bone? Lateral recess involved? Would expect L4 and 5 roots (not 5/1) involved if solely foraminal stenosis
Need to check on the official MR read.

You're absolutely right about the roots... wasn't thinking about it when I typed it. It would be best clarified once I have the entire story. I believe foraminal stenosis from recurrent disc and boney osteophyte. Just haven't heard of many people getting foraminotomies -- not sure what the outcomes are for these... though Im sure it is "case dependent"
 

Fiveoboy11

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Not directly answering your question... but...

You're a smart dude.... so I'm sure he's already done appropriate PT, meds, esi, etc

Has there been a new MRI w/ gad?- ie any signif scar tissue encasing nerve roots?
Foraminal stenosis from what? New recurrent disc or combination of factors w/ bone? Lateral recess involved? Would expect L4 and 5 roots (not 5/1) involved if solely foraminal stenosis
What is "appropriate PT" ? Is it something a physician calls PT care when it's convenient for them versus otherwise when it isn't? I'd question any labeling as such as projected and fabricated unscientific nonsense, not to mention insulting, to physical therapists as they are the only legitimate professional to derermine appropriate versus inappropriate.
 

Taus

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What is "appropriate PT" ? Is it something a physician calls PT care when it's convenient for them versus otherwise when it isn't? I'd question any labeling as such as projected and fabricated unscientific nonsense, not to mention insulting, to physical therapists as they are the only legitimate professional to derermine appropriate versus inappropriate.
Oh come on now.... The meaning of my sentence was appropriate "conservative care", including PT, meds, esi, etc.
 

Bombesin

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Please don't feed the troll. This is a good question and it need not be hijacked by a discussion on semantics and perceived slights of PT vs doctors. I am likewise interested in the success of foraminotomies, more for bony/osteophyte stenosis. Unfortunately, I've rarely seen them performed in isolation. Most have been in conjunction with lami's, etc.
 

RUOkie

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guys, get your panties unwadded and listen to Taus. He is a smart guy. His points are very valid.
1) Don't look for the "official read" READ THE FILMS YOURSELF Stenosis is not stenosis. You know the clinical picture, use your anatomical skills and figure out if the level of foraminal stenosis on MRI is consistent with your exam.
2) with multiple surgeries, Epidural Fibrosis is part of your differential. If that is the cause of stenosis, then surgical interventions have horrible outcomes.
3) It is a big jump to go from foraminotomy to fusion. Why would instrumentation even be considered? If there is central stenosis, laminectomy and foraminotomy WITHOUT fusion is an option.
4) with ISOLATED neuroforaminal stenosis, foraminotomy is an excellent surgical outcome.
5) Has he had any interventions? Possibly for diagnostic purposes?

If you have not done so already, sometime early in your career, befriend a neurosurgeon or ortho spine surgeon and ask to scrub in with him/her on a bunch of cases. Learn what they do. It will help you long term, and is worth missing a day or two's income.
 

axm397

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I have seen great success with foraminotomies both in lumbar and cervical spine with the properly selected patients with the right surgeon. I am lucky that I have a great neurosurgeon that I refer to when my patients fail appropriate conservative management with PT (including mckenzie method for radicular pain looking for directional preference, etc.), injections if needed, and medications. I even offer referrals to chiropractic and acupuncture for patients who want to exhaust all conservative measures. He and I try to do the least amount of surgery possible/needed and we have seen good results with non-fusion surgeries including foraminotomies, laminotomies, laminectomies, microdiskectomies, etc. It's actually more profitable for surgeons to do fusions than these "micro" surgeries. I've also seen a lot of cases in the community where patients get laminectomies/laminotomies for unilateral radicular symptoms and they don't get better because central stenosis was not the main problem.
 
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