[jmarc]

#26603

Hi There,

Approximately 8+ months ago (Thursday before Super Bowl), I did a workout at 5am. Did some mobility work, stretching, single leg jumps and lands, push-ups, pull-ups, and some kettlebell swings. Felt great, was ready to start the day. Over the course of the day, my back really started to tighten up…to the point that by 5pm, I couldn’t stand without pain. Only relief I could get was via bending over and / or sitting down. Next day, was hobbling around and this seemed to feel “different” than past times where I aggravated my back. Left leg felt very heavy and weak, no power, felt noticeable difference in walking and going up stairs. Made it into a PT the next Monday (initial symptoms began previous Thursday). He couldn’t get a knee reflex on left side…and this is when I really started to become concerned.

Made it into CU Sports Med three weeks later. They did find a knee reflex, albeit a week one…and I had atrophy in left quad and hip flexors…and felt unstable, as if knee would sometimes just give out. I was not able to run…not out of pain, just couldn’t do it, no power to push off. The back (lower left, hip area) was really tight, but didn’t cause too much pain…unless I went into extension. My groin had a dull ache on left side. CU Sports Med immediately did an Xray and ordered an MRI.

Initial XR Findings:
Five nonrib-bearing lumbar type vertebral bodies demonstrate normal height and alignment. Multilevel disc degeneration, worst at L4-L5. Mile L4-L5 and L5-S1 facet arthrosis. SI joint spaces are maintained. Mild osteoarthrosis in both hips with abnormal step-off at the femoral head neck junction bilaterally.

Impression:
– No acute osseous abnormality
– Mild lower lumbar spine degenerative changes, worst at L4-L5
– Mild osteoarthrosis in both hips with femoral head neck junction anatomy which can predispose to cam-type impingement.

Initial MRI Findings (3.1.17):
Vertebral body heights are well-maintained. Mild disc space narrowing is present diffusely throughout the lumbar spine. Normal homogenous marrow signal is present. The included portion of the spinal cord demonstrates normal homogenous signal characteristics. The spinal cord terminates at the L1-L2 level. Limited evaluation of the included abdominal contents demonstrates no abnormality.

T12-L1: Normal
L1-L2: Normal
L2-L3: Minimal facet artropathy is present. There is no spinal canal or neural foraminal narrowing.
L3-L4: A small disc bulge is present. Mild facet and ligamentum flavum hypertrophy are present. There is no significant spinal canal narrowing. Mild bilateral neural foraminal narrowing is present, related primarily to a congenitally narrow canal.
L4-L5: A broad-based disc bulge is present with small central protrusion. A 7mm ovoid lesion demonstrating intermediate signal intensity on all sequences present within the left subarticular space immediately superior to the L4-L5 disc. The lesion produces mild mass effect on the adjacent exiting left L4 nerve. At the level of the disc space there is mild spinal canal narrowing related to the disc bulge with superimposed protrusion. Mild right and moderate left neural foraminal narrowing is present.

Impression:
1. A broad-based disc bulge with a superimposed central disc protrusion at the L4-L5 level contributes to mild spinal canal narrowing. A 7mm ovoid lesion demonstrating intermediate signal on all sequences with the left subarticular space likely represents a small sequestered disc fragment. Mass effect on the exiting L4 nerve is demonstrated. There is also moderate left neural foraminal narrowing.
2. A small disc bulge at the L5-S1 level demonstrates an associated annular tear.
3. Mild neural foraminal narrowing is present elsewhere at the mid and lower lumbar spine, related to the presence of congenitally short pedicles.

So that was in early March when I received those results. The doc then sent me on to the CU Spine Center. At that point, when I had my initial visit at CU Spine Center (3.28.17) I was two months out from initial onset of symptoms. My strength had started to improve in left leg; however, I was still having groin pain and heavy sensation. Sometimes heavy sensation would be upper anterior thigh; sometimes it would be wrapped around my knee. I started to notice that if I wore a compression sleeve, either on my thigh or knee, I would feel better. Doc at spine center said good news was he didn’t think I needed surgery (the fragment would be cleaned up by my body), bad news was that the disc would never be the same. Told me to get back into working out, stay away from dynamic trunk flexion and rotation for 4-6 months.

By June, I wasn’t feeling much difference. Still had dull ache in groin, tightness in low back (left), and heavy sensation in left leg that would come and go. Generally felt fine sitting, then after walking a bit would feel really heavy — again, sometimes in knee, sometimes upper thigh. Desperate, researched regenerative med options, settled on platelet lysate treatment in hip and spine (L4).

Before they would do the treatment, they sent me to get another MRI on spine and hip. This happened on 6.26.17.

Second MRI of spine Findings:
There is no impaired diffusion. There is mild low signal intensity in the disc spaces on the T2 images most pronounced at the L5-S1 level. The inferior thoracic spinal cord, conus medullaris, cauda equina and plexus structures are normal. There is mild disc space narrowing present at the L2-3, L3-4, L4-5 and L5-S1 level, more pronounced at L4-5.

L1-2, L2-3, L3-4: Bulging of the annulus is seen. There is no stenosis.

L4-5: There is a right central protrusion. There are small foaminal protrusions. There is mild left foraminal stenosis. The central canal is patent.

L5-S1: There is mild high signal intensity beneath the annular margin with a small central protrusion measuring less than 0.2cm. There is no stenosis.

The prevertebral and retroperitoneal structures are normal. There is no fracture or muscle tear.

Impression:
1. There is mild spondylosis
2. There are small protrusions at L4-5 and L5-S1. There is also a small annular fissure at L5-S1.
3. There is mild left foraminal stenosis at L4-5.
4. There is no central canal stenosis. There is no cord or plexus pathology identified.

So, second MRI of spine showed that the disc fragment had been resorbed…from what I was told.

The MRI of the hip Findings:
The bone marrow signal intensity of the inferior lumbar spine is normal. There is mild disc space narrowing at the L4-5 level. The alignment of the sacroilliac joints are normal. The illiopsoas muscle and tendon are normal. The obturator muscles, quadriceps mechanism and adductor muscles are normal. The sciatic nerve and piriformis muscle are normal. The alpha angle is normal bilaterally.

There is a tear of the left acetabular labrum extending from the anterior labral attachment at 9:00 position to the posterior superior labrum at the 2:00 position. This is mildly displaced less than 0.2cm. There is also mild osteophytes around the margin of the femoral heads bilaterally. There is thinning of the superior and lateral cartilage of the left femoral head and of the lateral third of the left acetabulum. The gluteal muscles and tendons are normal.

Impression:
1. There is anterior anterior-superior and superior posterior-superior left acetabular labral tear.
2. There is bilateral osteoarthritis of the hip joints. The joint space may be further characterized with standing radiography.
3. There is no fracture or bone lesion.

So… had the regen med treatment. Waited 10 weeks…not much improvement. Still have the heavy sensation that comes and goes…but pretty much always there. Again, if I wear compression sleeve, seems to feel better. I’m not sure why. Went to CU Hip Clinic — they want to do surgery on my hip, and he seems to think that the heavy feeling is coming from problems in my hip.

In meantime, I went back to CU Spine Center for a diagnostic injection (lydocaine only, no steroid) in L4 nerve root. For about 4 hours, my goin ache did feel better; however, not fully resolved.

I’m just looking for some answers here. I don’t really want to have surgery on my hip if I don’t have to. I know I have some issues (obviously); however, I don’t have any definitive answers to relieve this heavy feeling in my left leg, and dull groin ache on left side. I’m not in a ton of pain; however, it’s there…and my leg is heavy…and my back is constantly tight, with some pain in glute. I have classic symptoms of labral tear in hip; however, the heavy sensation in leg seems like it would be more nerve entrapment in L4-5 or L5-S1 area.

Standing, walking, moving brings on the heavy sensation.
Sitting, squatting definitely exacerbates groin issue (pinching).
Extension can also irritate groin and definitely is always felt in back.
Left hamstring constantly tight…never goes away.

I’ve gone from extremely active (weightlifting, sprints, hike, bike 5+ days week) to unable to really do much of anything for the past 8+ months. I’m desperate to feel normal again, to be active. Any help / advice is greatly appreciated.

[Donald Corenman, MD, DC]

#26649

As soon as I read the term “Kettle ball”, I had a good idea what your injury was. This device requires flexion, bending and load (the famous “BLT” that causes annular tears and disc herniations).

You had a significant compression injury to the L4 nerve with motor weakness (“Left leg felt very heavy and weak, no power, felt noticeable difference in walking and going up stairs”, I had atrophy in left quad and hip flexors…and felt unstable, as if knee would sometimes just give out”). Interesting is that I would have assumed an L3 nerve injury as your hip flexor (psoas muscle) was also out and that is not an L4 motor root. Nonetheless, you had an extruded herniated disc fragment at L4-5 that ascended into the canal and compressed the L4 nerve root (“A broad-based disc bulge is present with small central protrusion. A 7mm ovoid lesion demonstrating intermediate signal intensity on all sequences present within the left subarticular space immediately superior to the L4-L5 disc. The lesion produces mild mass effect on the adjacent exiting left L4 nerve”).

Normally with quad weakness, I recommend a micro disc surgery sooner than later to allow the nerve to have the best chance of recovery but that is now water under the bridge.

Now some of your symptoms could be also generated from the labrum tear. The easiest way to test this is to have a lidocaine injection into the hip joint after you aggravate the symptoms to see what relief you gain. That relief would be an example of what you could expect from a labrum repair.

I think you should still consider a microdiscectomy to help the L4 nerve heal the best it can under the circumstances.

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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