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- Sun Dec 12, 2004 12:30 am
I am 38 years old and I hurt my lower back when trying to move a heavy box. My MRI says 1. Mild Posterior Disk Bulge at L3-L4,L4-L5, and L5-S-1. 2. Moderate Central Canal Stenosis at L5. 3. Facet Hypertrophy at L3-L4, L4-L5 and L5-S1. 4. Mild Bilateral Neural Foraminal Narrowing at L4-L5. I realize there were some changes going on but I never had any pain before I moved the box. The pain was acute and it was eight months ago. The episodes of pain would come and go but now that I am at a different job which requires me being on my feet sometimes eight hours a day; this episode that started about month ago will not go away and continues to get worse. I wear a lumbar support brace, I have tried all medications to no avail, I have had a steroid injection, and do therapy along with home exercises. The pain has gotten so bad now that it is all I can do to work. Even sitting on light duty hurts. I go to therapy and wear my brace. My legs and feet are always tingling and will go completely numb; worse on the right side. The pain is getting excruciating and yet my doctor says that it helps to work all day and has me at full duty. All my life is just working because I need my job, the rest of my life is spent in bed or on the couch. I have three children to raise and I am scared that it is going to get worse and worse. My doctor says that therapy will cure me even though I am working forty hours a week and my therapist says that the therapy is not going to work if I do not rest it. Is therapy going to help? What are my options? I am at my wits end, is there a cure? Will I always live in this pain? Am I hurting myself more by working forty hours a week? What does all this MRI mean? It really hasn't been explained to me, I just know I hurt. Sitting hurts, standing hurts, my legs and feet always tingle and go numb when I sit, I have given my life up to pain this time and it has been a burden on my family and I have no quality of life in this pain. I am having another epidural, will this hurt me? Cure the problem? Hurt the problem? I am desperate and all I get from my doctor is "you will get through it." What tests can be done other than an MRI? What will they show? Since the numbness goes away, does this mean that I do not have nerve damage? What could I be doing to make it worse? Thank you for your time.
| Dr. A. Saif
- Wed Dec 15, 2004 2:44 pm
Dear Mrs" In Pain",
I am sorry to hear about your discomfort. Lets see if If I can start be explaining your MRI findings first., and I apologise if you know all this already.
Your spine as you know is made of vertebrae (the bony part) joined together in a chain by discs (like bags of jelly) and facet joints (sort of like hinges), and ligaments. Through the spine as you, probably know, runs the spinal cord and the nerve roots that supply the rest of your body with sensation and motor function. The cord and the nerve roots lie just behind the discs, and in front of the hinges, and the nerve roots leave the spinal canal through narrow gaps called the foramens (actually foramina).
The bags of jelly that allow the movement of the spine, can, because of degenerative chnages or do to an injury develop a weakness in its wall. This results in a bulge in the disc. The wall may actually rupture leading to extrusion of the jelly like material in the disc. The facet joints undergoing an arthritis process may enlarge. The ligament may appear to become thickened. On top of these four, there may be inflammatory swelling. All these narrow the space for the cord and the nerve roots in the canal and the foramina. This narrowing is called stenosis.
A lot of these changes can be occuring causing little symptoms over many years. Two types of pain occur. One is pain in your back itself. This is usually mechanical, due to the injury to the back, the arthritis in you facet joints etc. Then there is the radicular pain that is the pain caused by pressure on the nerve roots. Pins and needles are caused by irritation of the roots, numbness and weakness are caused by the compromise to the function of the roots.
Conservative (non-operative) treatment is based on the fact that most situations the pain is self limiting. The disc prolapses tend to shrivel over time, the swelling around arthritic facet joints also improve with the use of anti-inflammatory drugs, and physical therapy can sometimes "untrap" a nerve (although the main purpose of physical therapy is to maintain mmuscle tone in your back). Although corsets may reduce the mechanical component of the pain, they also induce wasting of the muscles. Muscle tone is important as a person in pain moves less, so the muscle weaken, and this leads to less intrinsic support of the back, leading to further mechanical pain. It is this the physical therapy is targetted against. The inflammatory swelling is addressed by the use of anti-inflammatories. Sometimes an epidural nijection of steroids may also calm down the angriness of the tissues and give the roots a little more room.
Operative surgery is indicated when there is intractable pain, when there is sustain eveidence of nerve function compromise (e.g. numbness that doesnot resolve, or weakness, e.g. a foot drop). If there is a large central disc prolapse, then there is a potential for a serious conditioan called cauda equina sysndrome to develop. Problems with your "water works" or your bowels, numbness in your "saddle" area are warning signs and need immediate attention, and possibly surgery.
Surgery however has its own complications (some graver than the problem that led to it), which is why there is a reluctance to use this as a first resort.
Please don't feel abandoned to your pain. Your doctor will try his (or her) best to find the best solution for you. Unfortunately, initially the best solution is patience, unless some of the critical signs I have mentioned are present. If things do not improve other interventions, including perhaps surgery will I am sure be offered.to you. I do hope things start to settle down, and hope that this information helps.
- Fri Aug 19, 2005 2:04 pm
Can someone make sense out of this MRI:TECHNIQUE:. Multiplanar MRI of the lumbar spine was petforrned using spin echo technique. T1 proton density and T2 weighted sagittal images as well as T1 and T2 weighted axial scans through the L1-2, L2- 3 L3- 4, L4-5 and L5- S1 disc spaces were performed.
FINDINGS:. Coronal imaging demonstrates a normal appearance to the spine. In the sagittal plane however there is obvious malalignment with a first-degree anterior listhesis of L4 on L5. The etiology is bilateral pars interarticularis defects. (The L5 vertebra is sacralized; a small diminutive L5-S1 disc is present and normal.)
At anatomical T12-L1, L1-L2, and L2-L3, there is a normal appearance to the disc margin, to the contour and size of the thecal sac, and to the exit foramina. At L2-L3, there is some fluid in the soft tissues immediately posterior to the left facet joint, likely a small synovial cyst. The canal at this level is normal.
At anatomical L3-L4, there is desiccation and narrowing of the disc height. There
is circumferential bulging of the posterior disc margin, accompanied by some osseous sparring to the left of the midline. Mild impingement on the base of the left foramen is present.
At the malaligned L4-L5 level the medial aspect of the right foramen is moderately narrowed; because of the rnalalignment the foramen is elongated in the anterior/posterior dimension and narrowed in the superior/inferior dimension. On the left side at this level a severe degree of foraminal impingement and likely compression of the exiting nerve root is observed. In addition, lateral recess narrowing is present. Some stress response in the left pedicle of L4 and in the left lemma of L5 is seen as T2 signal increase.
IMPRESSION:. 1. A transitional lumbosacral vertebra, with sacralization of the L5
vertebra and a normal-appearing but small disk at L5-S1 noted.
2. Just above this level, at anatornical L4-L5, bilateral pars interarticularis defects have led to a first degree anterior listhesis of L4 on L5. Moderate right and marked left foraminal narrowings are observed. Lateral recess stenosis is present bilaterally but the canal itself is not compromised and demonstrates typical anterior/posterior elongation.
3. At the anatomical L3-L4 level, the disc shows narrowing and desiccation. Mild left foraminal impingement due to left-sided osseous ridging is seen. The canal is normal in size at the disc space and shows some mild coronal narrowing at the upper endplate of L5.
4. All of the visualized interspaces above anatomical L3-L4 are normal. Each of the vertebrae, including L4 and L5 demonstrate normal contour and signal in the marrow space.
This is what a CT Scan indicated:"bilateral spondylolysis and a resultant grade 1-2 anterolisthesis of L5 on S1. mild proliferative changes in the facet joints at this level together with the spondylolisthesis is resulting in a mild posterolateral central spinal stenosis. otherwise normal computed tomography of the lumbar spine from L1-S1.
My general physician told me when an x-ray first showed my problem that the orthopedist he was referring me to would give me a PT program to follow and that surgery was the last resort. When I went to the orthopedist the only thing he said was surgery. When he went over that above MRi with my wife and myself he said that he thought therapy would not help in my situation but I opted for it anyway to see if I can get relief that way. I am just weary about back surgery and also wondering about the two differences in opinions of what route to go with my condition. anyone have any ideas?