I’m still off the ice trying to mend my back injury. I had an epidural steroid injection that helped some, enough to get me off a cane. Even after the injection, though, the only exercise I could tolerate was an exercise bike. I still couldn’t walk in the pool for exercise as my PT had suggested.
At my visit with Dr. A., my sports medicine doctor, he agreed that this level of function was not acceptable. Without being able to exercise more I wouldn’t be able to progress in PT. So we decided I should get a second steroid injection.
In addition to my sports medicine doctor I consulted a physiatrist (rehab specialist), Dr. H. Working with two different doctors for the same problem can be awkward, though in this case Dr. H is explicitly onboard with working alongside my sports medicine doctor and has sent him his notes. It’s great when the two agree: hard when they don’t.
Luckily they agree on the broad features of what’s going on, that my pain and weakness is along the path of the L5 spinal nerve and that the large disc extrusion sitting on that nerve easily explains that. And they agree on the general plan: PT, steroid injections as necessary, and if those don’t work, then surgery.
There are some differences between them. Dr. H thinks that if my nerve weakness hasn’t improved by when I see him again next week, I should get surgery soon, certainly by five months after the injury. He thinks if the nerve is compressed for too long the weakness could become permanent.
I’m not sure that Dr. A. believes that. While he thought I should find a surgeon so I’d have one I’m comfortable with in case I need surgery, he didn’t think it was urgent. He sent me to an orthopedist who told me that there’s no scientific proof that surgery will help heal the nerve, that it’s only reliable for getting rid of the pain.
While both docs thought I should get a second injection, Dr. H. considered it “more for surgical planning than anything else.” He wanted the injection done close to the affected nerve to prove that the pain was coming from that level. That type of injection (transforaminal approach) is slightly riskier than the injection I had the first time (interlaminar) but also thought by many to be more effective.
It certainly was more difficult to receive but it’s been worth it. It really helped the pain on the left, which has now become my less painful side.
It’s been a hard project for me to sort through the pros and cons of my options. Everyone agrees that herniations that are causing severe or progressive neurological symptoms need surgery, but for a mild nerve problem like mine opinions are mixed. Some studies suggest that outcomes are just as good without surgery if you wait long enough. Others, like the largest randomized controlled trial (RCT), the Sport Trial, show a better outcome for surgery.
I’ve been through enough medical decisions by now that I just sigh when I read that more research and particularly more randomized clinical trials are needed. There’s so little study of surgical outcomes compared to the extensive investigations required to put a new medication on the market.
I’ve done my best to read some of the relevant literature, things like how likely my ankle weakness would be to recover after surgery. It looks like my chances are pretty good on that front, especially since the weakness is not that bad (the involved muscles have a strength of 4 on a 1-5 scale, with 5 normal). I’ve also tried to research whether or not surgery produces a better outcome for recovery of muscle strength.
I’ll be further grilling my own doctors and any other surgeons I see on those points. The main reason for me to have surgery, in my mind, is if it’s going to give me a better chance of full neurological recovery. As far as pain, it’s improving and I’m probably over the worst, so I wouldn’t have surgery for that reason alone.
I’ll see both Dr. A and Dr. H. next week and see what they say. Meanwhile I’m riding the exercise bike and trying (with only intermittent luck) to stay patient and keep up hope that I’ll be able to skate again eventually.