Question
I am a 35yo who recently had microdiscectomy (L4-5) in February after a cough that resulted in two free floating disc fragments.  Surgery went well and I was pain free and resuming regular activities at the time of my follow-up visit 4 weeks after surgery.  About a month later, I began waking up each night after about 3 1/2 - 4 hours of sleep with horrible lower back pain and stiffness.  I would only obtain relief if I got up out of bed and walked around for a few minutes.  I would fall back to sleep and wake up every hour with the same pain/relief-when-I-walked cycle.  Oddly, I am completely pain free during the day.  I went back to the surgeon and had x-rays, a CT scan, and another MRI.  The surgeon (after ruling out infection) said that I have "endplate swelling" and that "in time" I would get better.  We tried steroids (oral and epidural) which were ineffective.  I've searched the web for information about "endplate swelling" and came up empty.  What can you tell me about this complication of surgery?  Is waiting this out my only option?

Answer
A microdiscectomy "trims" the disc, it doesn't or shouldn't involve the endplates.

Endplates are the top and bottom portions of the vertebral body, they do enlarge, not from swelling but from arthritic change. I suppose anything can swell, but a bone that is traumatized only expands microscopically and puts pressure on the periosteum causing periostitis. This would likely respond to steroids, since it didn't, the diagnosis needs to be looked at.

Get another surgeon to look it over that has nothing to do with the present doctor, preferably as far away as you can. (They all know each other and are sensitive to criticism);)

Here is what he is saying........


Periosteum
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Periosteum

compact spongy bone

Meninges of the CNS
Dorlands/Elsevier p_13/12628368
The periosteum is a thin layer of dense, irregular connective tissue membrane that covers the outer surface of a bone in all places except at joints. (The outer surface of bone at joints is covered with a type of hyaline cartilage called "articular cartilage".) As opposed to osseous tissue itself, periosteum has nociceptive nerve endings, making it very sensitive to manipulation. It also provides nourishment by providing the blood supply. The periosteum is connected to the bone by strong collagenous fibers called Sharpey's fibres, which extend to the outer circumferential and interstitial lamellae.

The periosteum consists of an outer "fibrous layer" and inner "cambium layer". The fibrous layer contains fibroblasts while the cambium layer contains progenitor cells which develop into osteoblasts that are responsible for increasing bone width. After a bone fracture the progenitor cells develop into osteoblasts and chondroblasts which are essential to the healing process.It also acts as an attatchment for muscles and joints.

The periosteum that covers the outer surface of the skull is known as the "pericranium".



Definition of Periostitis

Periostitis: Inflammation of the periosteum, a dense membrane composed of fibrous connective tissue that closely wraps (invests) all bone, except the bone of articulating surfaces in joints which are covered by synovial membranes. The word "periostitis" may seem like Greek to you. "Peri-" is a prefix borrowed from the Greek meaning "around or about", "- osteal" comes from the Greek "osteon" meaning "bone", and the Greek suffix "itis" meant "disease" and now, more narrowly, means "inflammation." So periostitis literally is inflammation around the bone.

I never heard of "endplate swelling" as being a diagnosis for postoperative pain.

I would get another opinion,

Dr. Timothy Durnin
drs.chiroweb.com