Met with Dr. Mudiyam earlier this week. While Diane appeared to respond well to ESI, she thinks she was responding well to zero activity in the days following ESI. Unfortunately, the respite from symptoms was less than 1 day (the day I wrote the 'much improved' post.) He thinks she's a non-responder and recommended surgery... microdiscectomy scheduled for mid July.
Met with Regan today... it was great to get an unbiased opinion (as he is not a possibility for surgery) from someone we trust. Remember that Diane knows Regan since 2001 when I was seeing him as a patient and has seen him over the years at GPN events. I asked Diane to see him because over the years, I've sat in Regan's office with many clients who faces similar decisions. In some cases, he told them that they must wait and doing early surgery is not appropriate. In other cases, he's recommended surgery. I knew many of the issues that color his opinion, but this was a great opportunity to get into even more depth. Just a few of the issues....
>> While some surgeons expressed that working on 'fresh' herniation is better than one that's sat for a while, Regan thought that waiting another month or two is not significant in terms ease of surgery or a significant change in potential success rate.
>> Diane is very concerned about permanence of neuro deficits. While she does not have any of the red flag symptoms, she does have mild to moderate symptoms including some strength loss. (not severe enough to cause foot drop or to keep her from doing multiple heel raises, but there is loss of strenght in a few areas. At this level of impairment, Regan does not think that she's at risk for permanent loss, but he expressed that the longer you leave it, the longer the recovery. Again... not too important in the big scheme of things... waiting OK
>> How long do we wait to see if she's a non-responder? His take was 2 to 3 months. If not improving at a couple of months, it's unlikely that the patient is going to have a stellar recovery. Certainly, it's OK to wait a 3rd month and even do another epidural, but in his experience, if she's getting worse at 2 months (which she is), then the risk of damage, inflamation, scar tissue, etc... associated with the ongoing painful situation is increased by waiting. (obviously, this is to be balanced against the risk of surgery.)
>> Microdiscectomy at L5-S1 is a straightforward and easy operation with little collateral damage and high chance of success. While it's a great idea to treat conservatively to see if she's a positive responder, continuing to treat a non-responder conservitavely implies months of suffering and higher risk down the road... compared to 'nipping it in the bud' and getting on with healing from surgery instead of dealing with the ongoing inflammatory process.
Diane has been leaning towards 'nipping it in the bud' as soon as she saw how severe the herniation was. I've been leaning towards giving it a chance to resolve on it's own. She's new to being a spine patient and sees months of suffering as highly important. I've lived it for years and feel that a few months of suffering is completely insignificant in the big picture.... only the highest chance of long term success matters. As with all things spine... there is no clear answer. She may be a long term success no matter which path she chooses. She may have more problems down the road no matter which path she chooses.
It's very interesting going through this process with my wife. I face many of these issues every day with my clients... this is different. It is similar in that as with my clients, I am sticking to my guns and only seek to help her to make an informed decision... not to persuade her one way or another. I think she's choosing early surgical intervention. If it were my spine, I'd do more ESI's and wait longer, but her approach is every bit as valid. She understands the issues and has done a good job in becoming informed. It's actually a relief to me that she's not following what I'd do for myself... so I'm sure that it's her decision and not mine.
This is a good operation with good results. We get a bad view of things in the patient community because the folks that have successful micro-d and never look back are not here... only the ones who graduate to more surgery and more problems are represented here. We are both comfortable with her decision and are looking forward to success.
We'll keep y'all posted.
Mark
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