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conservative treatment vs surgery for l5/s1 disc bulge


I am new to this forum(or any forum).  I have read alot of the conversations on this site, trying to gain insight into my current situation.

I was active and without pain until some heavy yard work in November gave me sciatica with severe disabling pain. After two trips to the ER and getting an MRI, it was determined I had an l5/s1 disc bulge impinging on the s1 nerve. I also have a minimal grade 1 spondylothesis and bilateral pars defects at l5. I have no back pain, but had severe, disabling left-sided butt/leg pain due to radiculopathy. Over the past four months, I have been treated conservatively--multiple pain medications, three epidural steroid injections, and now physical therapy. My pain level has gone from a 10 to about a 5, but I am not able to sit or stand for very long without pain increasing.I have never had any pain like this before, and I have become very frustrated and anxious as a result. I think my level of improvement has plateaued, and I am considering surgery. A neurosurgeon would perform a discectomy. (An orthopedic surgeon wants to do a fusion due to the pars defects.) I am still told that I have improved, and should continue to do so, but I am not sure how long I can hang in there--I can walk, but not sit or stand for long, and the pain is still controlling my life and ability to function.

Any suggestions on how long to pursue physical therapy and exercise, before resorting to surgery? I was told the discectomy surgery should resolve the leg pain. Has anyone had the pain, weakness, and function resolve after months of pt and exercise? I am also concerned that the sciatic nerve will be permanently damaged if it does not get decompressed in the near future.




  • LizLiz Posts: 9,760

    hello sdb

    welcome to spine health

    there are no medical professionals on this forum side of the site. therefore, no one is capable or permitted to provide any type of medical advice.

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    Veritas-Health Forum Moderator

    Spinal stenosis since 1995
    Lumber decompression surgery S1 L5-L3[1996]
    Cervical stenosis, so far avoided surgery
  • It’s only been four months. Going from a 10 to a 5 is excellent. I would avoid surgery if at all possible. Maybe see how you’re feeling eight weeks from now and revisit the surgery option.

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  • MarWinMarWin OhioPosts: 705

    @sdb I had sciatica for over two years. Full blown symptoms and pain level. It took me a lifetime to get into that condition. The silver lining is that it took me four months to get out of pain. I had low back pain for over 25 years as well. I most definitely agree with @L4_L5 that now is not the time to become discouraged. 

    To say that any one situation caused it would be a mistake. This statement deals with chronic pain so don't get me wrong if you've had a traumatic injury to the area affected. In that case you have something tangible to blame. What I am saying is be careful of blaming yard work as the cause of sciatica. True, it may have been the last-draw that sent you over the top, but most likely other factors should be included in the blame.  

    As for the surgery (discectomy), ask yourself "When they remove the bulge what will they have done to address why there was a bulge?" For spondy, isn't that when one vertebrae protrudes out over the other? Vertebrae are bone. Muscle moves bone. Just a thought, and wondering if muscles are the true culprit?   

    Praying you don't have to get a fusion  o:)

  • Just IMO but I would take the opinion of a neurosurgeon over an ortho (for a disc issue) any day of the week. 

    Therefore if the neurosurgeon is saying microdisectomy and the ortho is saying fusion that bodes well for you IMO.

    What it probably means is the ortho is being overzealous in suggesting a fusion. 

    Nobody wants a fusion if a microdisectomy will do the trick.

  • MarWin,

    Thank you for your insights. I think years of doing lots of landscaping in two different homes with huge gardens, combined with not knowing my limits has put me in this current sciatica situation. I never had any back pain--maybe no discs were hitting nerve roots--so I never knew I could cause a significant back injury. I do not want a fusion, and the pain management doctor and neurosurgeon only suggested a discectomy to decompress the nerve if the pain symptoms (which were excruciating) had not resolved. I was told the pars defects, and the minimal grade 1 spondylolithesis which were found on the MRI could have been there since birth--and the cause of my current pain is the bulging l5/s1 disc on the s1 nerve.

    It is interesting that you mentioned muscles. The physical therapist who is treating me said my main problem  is my butt/hip muscles. Everything is in a spasm and very painful to do the exercises. He thinks the muscles are clamping down on the sciatic nerve. He is treating me for piriformis syndrome, tight hamstrings, and also weak muscles since I have avoided any exercise since my injury in November. I probably had very weak core muscles when I was doing all the yard work last fall.

    I don't know how you coped with two years of sciatica. To what do you attribute your four month recovery? Surgery, physical therapy, a miracle? I want to get motivated to increase my exercise and improve my attitude, but I am afraid of severe pain returning.

    Thank you, and please let me know what you did in the four months to recover.


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  • Thank you L4_L5 for responding and for the encouragement to keep trying.  It is very useful to get someone's opinion who has personal experience with this condition. I could not believe the different treatment approaches among the various doctors I have seen. Treatments range from fusion, to microdisectomy, to pain management medications, to "suck it up and shut up" (from my primary care doctor). Even the physical therapist is treating me for muscle problems, vs. herniated disc. I know I have a problem, but it is confusing when people do not have a common treatment plan for me.


  • tjlazerttjlazer TacomaPosts: 44

    I agree avoid surgery unless the disc bulge is more than 8mm and is causing a LOT of pain!  I would look into Spinal Decompression to see if that helps.  A small herniation has a very bad surgical outcome.  That would be me.  My surgery was a failure, still have lots of Sciatica.  My bulge was way less than 8mm.

    a good resource is chirogeek com on all this stuff

  • Reddog53RReddog53 Posts: 8
    edited 03/15/2018 - 4:48 PM

    Saw 3 different surgeons, two ortho and one neuro. Three different diagnoses at two locations. Had a posterior lumbar micro-decompression and bone spur removal at L4/5 in December for radiculopathy.  So 3.5 months out and pain level is down from an 8 to a 3/4 most days. The pain is no longer burning, but more like a toothache. The doctor can feel the heat from the nerve on the back of my leg. 

    Plan is to start PT next week for two months, if no improvement, an epidural (again), if no improvement, consider a TLIF L4/5. I am still vacillating on the PT as my PA said, "Oh, you will definitely need pain meds with the PT". I hope that you have a continuing resolution to your pain. 

  • First of all,  I agree with trying all other options before deciding on surgery. 

    I did, however, want to weigh in with a comment regarding Ortho vs. Neurosurgeons.

    I had three opinions prior to surgery- two neuro and one ortho. Both Neurosugeons recommended laminectomy's, but stated I may need fusion at a later time. If I had gone the route of the lamis, I would've had to have fusion at a later time. What's the point of "minimally invasive" if you have to have repeated surgeries?

    I have degenerative scoliosis, so I realize it's a different condition than what you all have been discussing. But I believe my Orthosurgeon's diagnosis and treatment were right on. 

  • Reddog 53,

    I have been going to physical therapy for a few weeks, and trying hard to restrengthen muscles in legs, butt, and back, in order to avoid surgery.  The muscle pain in my butt and hips has gotten alot worse with the pt and daily stretching exercises.  I don't want sciatica down both legs, and now my hamstrings or sciatic nerves on both sides now are alot more aggravated. I have 2 spine problems--a protruding l5/s1 disc and a grade 1 spondylolisthesis at l5. The back extension exercises and press ups which the therapist is having me do are for the disc herniation. The treatment for sponylolisthesis is supposedly no extension, but more flexing, which is not good for the disc herniation. So even the therapy is a conflicting situation.


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