benbuxton2MemberApril 21, 2012 at 10:13 amPost count: 2
Dr. Corenman – First of all I wanted to thank you for the tremendous amount of useful information on your website – it has been very helpful in better understanding the anatomy of the spine, diagnosis, as well as treatment options.
I am a 46 yr old male who has been a competitive endurance athlete for many years including road cycling, mountain biking, and nordic and alpine skiing. I have managed several L5-S1 disc injuries over time and have been able to manage these injuries with conservative care including physical and massage therapy, manual therapy, as well as focused core strength training of deep stabilizers of the core and back. Within the past year, I have also included pilates strength training and found it to be very helpful.
In Nov. 2010 after rigorous mountain bike training, I had another flare up of back pain, and begun conservative care, but with limited to no success. In May 0f 2011, I underwent several steroid injections without significant relief. In June of 2011, I incurred a significant herniation at L5-S1 and experienced significant pain (9/10) and began to suffer nerve pain and loss of function (dorsal flexsion) in my left leg. Upon seeing a spine surgeon and review of my lumbar MRI, it was determined I needed a micro-discecotmy to relieve the excruciating back and leg pain and relieve the pressure on spinal nerves. The surgeon removed a significant disc fragment and after several months of recovery I was back to my activities, but still was experiencing back pain in the 2-4 range.
I’ve had 2 significant flare ups since Nov. 2011 and have continued to manage it conservatively, but have not been able to get to the level of athletic activity I want to be at. My most recent MRI from Dec. of 2011 (post surgery) showed that I continue to have a small-moderate sized broad based central disc protrusion with an associated annular fissure at L5-S1. There was additional mild degenerative spondylosis and mild to moderate DDD as well as difuse buldging of the disc annulus and minimal bilateral neural foraminal narrowing at the L5-S1 level. While there was minimal vertebral body end plate osteophyte formation at both L4-L5 and L5-S1, L4-L5 showed no signs of annular fissure or disc protrusion.
That brings me to now. A week ago, I had yet another flare up after alpine skiing. I have gotten to the point where I need to consider the next steps to provide me relief. After nearly 18 months of on and off back pain and surgery, I’m now seeking out whether to pursue a fusion such as a TLIF. I have consults scheduled with 2 spine surgeons in the Denver area in the coming weeks and would appreciate any advice you can provide. My questions include:
1. Do you think a discogram would be a useful diagnostic tool for my condition?
2. Are there any other conservative care options I could consider?
3. Given my history and desire to return to athletic activity, do you think a lumbar fusion would be a good option for me to address both the pain and return to my desired level of activity?
I’m at the point where I feel like my life has been on hold for nearly 2 years and the chronic pain is always there and I really need to figure out the next steps. One thing that sticks with me is how you’ve discussed that disc injuries are cumulative and it seems that my disc injury has advanced to the point where it’s beyond continued conservative care. In the end, I’m desperate to return to the life I’ve enjoyed and move beyond this injury.
Thanks…Ben B.Donald Corenman, MD, DCModeratorApril 22, 2012 at 3:40 amPost count: 8459
By your history and the sounds of your symptoms, you would probably be a candidate for a TLIF at the L5-S1 level. I am somewhat concerned about the osteophytes at L4-5 but if that disc has a normal appearance, you should be OK with just an L5-S1 fusion. The discogram is important if there is some confusion regarding the symptoms or the appropriateness of patient selection but I don’t believe that is a concern in your case.
You have already undergone reasonable physical therapy and rehabilitation and epidurals with continued symptoms. You can try chiropractic treatment if you so desire. Other than that, you are probably a candidate for fusion surgery.
Dr. Corenmanbenbuxton2MemberApril 22, 2012 at 12:32 pmPost count: 2
Thanks for the info and opinion on me being a candidate for a TLIF.
With respect to the osteophyte at L4-5, what is the potential concern relative to doing the L5-S1 fusion? The radiology report terms it as marginal and minimal, but am interested in potential issues.Donald Corenman, MD, DCModeratorApril 22, 2012 at 10:40 pmPost count: 8459
Osteophytes can be an indication of an enthesopathy which is an abnormal motion of a vertebra causing a pull on the insertion of ligament. This might be a finding that can cause no particular problem but I always look more carefully at this disc level if bone spurs are present. There are other non-worrisome disorders that can cause these spurs like DISH (diffuse idiopathic skeletal hyperostosis).
If the disc back wall is jet black and flat to concave on the axial MRI T2 and the sagittal MRI demonstrates a well hydrated nucleus (back wall of the jelly donut is jet black on the top down view and on the side view, the disc looks like all the others except L5-S1), there probably is no significant problem with the disc.
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