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Dr. Corenman,
I apologize in advance, as this will be a lengthy post.
I need to give you a little history: In early 2003 I began having a lot of lower back pain, which eventually spread to my right leg. I had 3 young children, so I put off going to my doctor for nearly 2 years. In late 2004, I did go and had an MRI done. The results had my family doctor sending me to a neurosurgeon immediately. I’m sad to say I don’t have the MRI report at this time, and I don’t recall a lot of the specifics, but the main thing was a ruptured disc (it was gone by this time) at L3-L4 and spondylolisthesis. I remember being told as a simple explanation that the disc was gone, and some bone (facet joint, I assume) had broken off my spine and the vertebra were sliding against each other and that I had some arthritis there, also. I did the standard insurance requirements: PT and injections, etc. before finally having the laminectomy and fusion at L3-L4 in June of 2005. I had nearly lost the use of my right leg, I couldn’t walk for more than 10 minutes without being in terrible pain. The reflex was gone, also. The surgery, recovery and bone fusion went beautifully, with full use of the leg returning and absolutely no pain or numbness. The reflex has never returned.
In 2009, I went back to work after staying at home for 10 years with the children. I chose to get licensed and become a CNA. I worked full time for 2 1/2 years, without a problem. No back pain…I was just ‘normal’. In Sept. 2010, I injured my back at work. MRI showed a herniated disc at L2-L3, among other things. And so I began the process…Same neurosurgeon that did the fusion told me this one did not need surgery, and sent me off to Pain Management and Physical Therapy. I did 6 weeks of PT (land and water) and started injections (nerve root blocks) as the prescribed medicines were not really helping. I had pain in my back, left hip and leg. Numbness to my knee joined in. About three months into this, the pain was worse, the numbness worse (now I had a tingling sensation that would come and go) and it began to go below the knee all the way to my toes. Still getting injections at this point, they were not working very well. I couldn’t walk, sit, stand, etc…for any real length of time without having to change position. My leg became weak and would sometimes give out on me. My workers comp had me go for an EMG/NCS. Results were ‘no muscle or nerve damage’. WC then had my do a FCE, which I managed to get through with sheer will (I wanted to go back to work!) Results were decent, they said I could work ‘light duty’ and ‘maintain a 8hr day/40hr week’. After 4 months now, I started back on light duty in Jan. 2011. I was still getting injections. My pain and numbness continued to worsen to the point that I felt unable to work some days. I began having terrible cramps in my left leg at night after I went to bed. I have them every night, and I don’t remember what sleep is. Pain Management sent me to another neurosurgeon last week for a second opinion. He looked at the MRI that was done 6 months ago, examined me, asked some questions and then said he didn’t feel surgery was needed at this point. He said the symptoms I’m having now aren’t from the herniated disc, rather from the arachnoiditis. He said I had scarring on the nerves and they were clumped together. He gave me some samples of Lyrica and sent me back to Pain Management. I was taking 75mg two times a day. The pain went away for 2 days, but the side effects were so bad that I couldn’t function, much less work. PM reduced it to 50mg twice a day, and the side effects lessened but the pain returned full force. Now I’m at 50mg three times a day, side effects coming back and pain is not going away yet.
I’m sorry, I told you this would be long…
Here is the report from my MRI. I am pasting it from a text file so I hope it displays properly.
BEGIN
MRI of the LUMBAR SPINE WITHOUT and WITH IV CONTRAST:
TECHNICAL: Sagittal T1, FSE T2, inversion recovery, Axial T1
and T2 sequences from L2-3 through L5-S1 were followed by
contrast enhanced (15 cc Magnevist) axial and sagittal T1
sequences. The examination is interpreted assuming there are 5
lumbar vertebra with the lowermost labeled L5 on this study.
Plain film correlation would be necessary prior to any type of
intervention. Indication: Pain LLE. Comparison: none.
FINDINGS: The paravertebral soft tissues are normal.
Normal termination of the conus is seen at L1.
There is a normal proportion of hematopoietic bone marrow and
fat for this patient’s age. Vertebral height is normal.
The patient is post L3-4 laminectomy and L3-4 fusion with
pedicle screws and accompanying metal artifacts. There is grade
1 degenerative retrolisthesis at L2-3. There is mild
postoperative dural ectasia at L3 and L4
The L2-3 disc space level is mildly narrowed and there is
decreased T2 signal of dehydration in the L2-3 disc.
.
L1-2. Sagittal sequences only were obtained. No disc
abnormality is seen. There is no evidence for significant
central canal or foraminal narrowing.
.
L2-3. There is degenerative retrolisthesis, facet arthropathy,
diffuse posterior disc bulging and posterior leftward disc
herniation. The retrolisthesis, broad-based disc bulging and
facet arthropathy cause mild central canal stenosis, mild right
and moderate left foraminal stenosis. The lateral protruding
disc effaces the fat lateral to the left neural foramen and
abuts the left nerve root distal to the foramen. The nerve
roots are clumped posteriorly in the thecal sac compatible with
arachnoiditis.
.
L3-4. Laminectomy. No significant central canal stenosis, nerve
root compression or neural foraminal narrowing allowing for
metal artifacts.
.
L4-5, L5-S1. No focal disc bulge or protrusion. No evidence of
canal or foraminal narrowing. Facet joints are unremarkable.
.
Tarlov cysts are noted at S1 and S2. The larger cyst at S2
causes bony erosion of the dorsum of the vertebra.
.
IMPRESSION: Lumbar laminectomy and fusion. Retrolisthesis at
L2-3, disc bulging and leftward herniation cause moderate left
foraminal stenosis and compromise of the left nerve root distal
to the foramen.
ENDI know without actually seeing the images, you can only go by what I’ve told you and what the report says…but I would like to know if you think that the diagnosis of arachnoiditis is most likely correct? I’ve done tons of research in the last few days, which led me to this site. I watched your videos to try to learn how to look at my MRI, since I have the CD. I’m terrified of what’s to come if this is truly my diagnosis. I noticed that nowhere on this site do you mention arachnoiditis, so I wondered what your opinion would be. Oh, and I guess I should say that I’m 42, 5′ 7″ and about 165 lbs and otherwise in excellent health.
I sincerely thank you for your time and attention. You are providing a wonderful service here for those of us who are basically lost in all this.
I’m going to work backwards here. Let me start by stating that I will have a complete description of arachnoiditis in the next 6 months on this web site but unfortunately that doesn’t help you now. First- let me state what arachnoiditis is. The nerves in the spinal canal are surrounded by three membranes, the Pia mater, Arachnoid and Dura mater. The Dura holds in the cerebrospinal fluid, the salt water that your brain and spinal cord float in (remnants from living in the ocean at one time).
Arachnoiditis is exactly what it states- inflammation of the arachnoid. This can occur when there is compression of the nerves as in spinal stenosis (like you had previously), meningitis (the meninges are the lining of the nerves which includes the arachnoid), trauma or in the old days, the use of an oil based myelogram which was used to image the nerves prior to the MRI. We now have water based myelograms which do not cause arachnoiditis- thank God.
Arachnoiditis may cause symptoms but many patients with this problem have no symptoms- so don’t despair. The report from the radiologist does not note the presence of arachnoiditis, which does not mean it is not present, but it may not be there. You will find interpretation of films is not an exact science but dependent upon the skill of the physician.
So lets start at the beginning. The pain in your back and leg very well could be from the degenerative spondylolysthesis, central stenosis and foraminal stenosis at L2-3. The EMG will typically be negative (normal) if the nerve is not severely damaged- which is typical for this condition and therefore not a great test.
You must separate back pain in your mind from leg pain. If your leg pain occurs more with standing and walking and is relieved by sitting (not back pain but leg pain), the leg pain more likely than not is from the stenosis. Which side is the leg pain the worst? If your back pain is worse from sitting and lifting, this could be instability from the L2-3 segment. Don’t worry about the Tarlov cysts as these are common and typically asymptomatic.
See the section on SNRBs or selective nerve root blocks as this in my opinion is your next test to determine if surgery can be helpful. Get a new set of expert eyes on your diagnosis.
Good Luck!
Dr. Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.Thanks for your quick response.
I didn’t think it was worth mentioning, but considering your reply I wanted to add that I did have a myelogram done in the early 80’s, probably around ’84. I had been told I had a tiny broken bone at the base of my spine, so I’m assuming that it was maybe S4 or S5. I was about 15 at the time, and wore a brace for around 3 months, and was told after that the bone hadn’t healed. I don’t recall much more about it, just that after the myelogram, a nurse lowered my bed flat that night and the next morning I had a migraine that lasted for nearly 2 weeks.
Also want to add that in the last 2 days, I have begun to have pain and tingling in my right hip, leg and foot, and my right foot is slighty swollen. I have not had any type of pain on the right side since my surgery 6 yrs ago. My lower back pain is present all the time, but increases with walking and sitting. The pain and numbness/tingling in my left leg is present all the time, and increases with walking. Sitting eases the leg pain somewhat, but not the numbness. Tingling gradually increases the longer I sit. As to the right hip and leg…I’m currently off work for several days, and it’s a new addition, so I’m not sure yet how it will react.
I have already had the SNRB done…in my previous post, I referred to them as ‘injections’. I had the first one on 11-8-10, which used Lidocaine, Triamcinolone, Saline, and Isovue. 11-22-10 used Lidocaine, Triamcinolone, and Saline. Also on 1-3-11, and 2-7-11 with the same three. On 4-4-11, was my most recent one using Lidocaine, Triamcinolone, Saline and Isovue.
The first 2 reduced the pain to a somewhat bearable level, maybe about 50 percent. The 3rd maintained the relief but no improvement. The 4th only helped maintain for about 3 wks, then the pain started to increase, going from a 2-3 to as much as a 7-8. My last one on the 4th of April did nothing.
I am going to attach some images of frames from my MRI on another post. I’m not asking for a diagnosis, but an opinion on whether or not I should ask for another MRI, as this one is nearly 7 months old, and if you believe I should have another done, is it your opinion that I should ask them to specifically look for signs of arachnoiditis?
If you cannot express an opinion, I understand. Again I thank you for your time.
Images named Frames 1 – 18 are from series marked SC:Ax T2 UPPER
Images named Frames 19 – 20 are two from series marked
SC:SAG T2ETA:
Won’t allow me to attach the images.The information that you need me to look at is too complex for this website. Please call my office at 970 476-1100 and talk to one of my nurses. They can give you the address so you can mail your films to me for further discussion.
Dr. Corenman
PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books. -
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