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  • Littleshell09
    Member
    Post count: 7

    Dr Corenman,
    On a previous post I’d asked your advice on pain issues I’ve had with my cervical & lumbar spine since last May (2012). You’d recommended flexion/extension x-rays of both areas & I finally was able to convince my doc to order them. I was diagnosed with spondylolisthesis at 12, it reared its ugly head during all 5 of my pregnancies & I’m no stranger to back pain. This is what I learned from x-rays:
    Cervical spine: 4 mm anterolisthesis in flexion & 3 mm in extension, end plate changes at multiple levels; fusion C5-7.
    Lumbar: 7 mm anterolisthesis L4 on L5 with flexion & 4 mm with extension, multiple end plate changes, bilateral pars defect, hypertrophy of facets.

    Getting adequate pain relief has been a big issue for me. Currently they have me on baclofen 10 mg TID prn & Ultram 50 mg TID prn. Spine doc wants me to try cymbalta as well, but wants PCP to prescribe it. Basically, it’s been explained to me that many people have these degenerative changes & no pain. I feel somewhat patronized & frankly I feel treated as if my pain is psychogenic. However, prior to this I was running 6 to 8 miles/day & going to the gym 3 to 5x/week. My question is whether these changes warrant any interventions beyond PT, with which I’ve been compliant? It’s starting to feel very frustrating. I’ve had pain daily for over a year & traction actually made lumbar pain worse although it seemed helpful for cervical pain.
    Respectfully,

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    You have what I like to call CBS and CNS (crappy back syndrome and crappy neck syndrome. Your genetics are such that the discs break down early and you develop pain from this breakdown.

    In regards to the lumbar spine, when you say “multiple endplate changes”, do you mean that endplates other than at L4-5 are affected or is it only the L4 and L5 endplates involved? The same question for the cervical spine. How many endplates are affected?

    Are the endplates fractured or highly irregular (same problem). How much disc height is lost? Is there abnormal alignment from degeneration of the discs (degenerative kyphosis)?

    What are your symptoms? Do you have mainly back pain or is there leg pain involved? Same for the cervical spine. Neck pain vs. shoulder and arm pain?

    The L4-5 level is obviously unstable with a 7mm slip that changes by 3mm with motion. Even with changes at other levels, this is more likely going to be a significant pain generator. I am surprised that you surgeon has not discussed surgical stabilization if you have significant symptoms and have failed all other forms of therapy.

    It is harder to understand the pain generation in your cervical spine. It certainly could be from the degenerative spondylolisthesis in your neck above the prior fusion. I would need to review the films along with a good understanding of your pain in the cervical region to have an opinion.

    Dr. Corenman

    Littleshell09
    Member
    Post count: 7

    Pain continues, inadequate relief. NSAIDS cause severe esophageal & GI gastritis, confirmed by gastro specialist … What can you recommend at this juncture? I’m in severe pain daily & my QOL is greatly reduced. I’ve been offered flexeril 10 mg HS, cymbalta – that’s about it. Is there adequate justification here for the pain I’m experiencing? Thank you!
    Health Record: Reports

    Patient:
    Reports

    For more information about a report, please contact the Ordering Provider. [More]
    Report

    Print
    Exam Number: A13315085 Report Status: Final
    Type: MRI SCAN LUMBAR SPINE WO CONT
    Date/Time: 12/14/2013 13:10

    REPORT:
    INDICATION: Chronic severe pain. Per EMR, low back and bilateral thigh pain.

    TECHNIQUE: MRI of the lumbar spine was performed on a 1.5 T
    magnet without intravenous contrast. Sequences include sagittal
    T1, sagittal T2, sagittal STIR, axial T1, axial T2.

    COMPARISON: None.

    FINDINGS: Study assumes 5 lumbar type vertebral bodies.
    Vertebral body heights are preserved. Conus terminates at T12-L1
    and cord signal is normal. There is multilevel intervertebral
    disc desiccation and moderate intervertebral disc narrowing at
    L4-L5. At T10-T12 and also from L2 to L4, there is also
    Schmorl’s node formation. Focal T1 and T2 hyperintense signal
    within T12 is either a hemangioma or focal fat (se 3, im 11).
    There is mild anterolisthesis of L4 on L5 measuring 3 mm.

    Specific findings are seen at the following levels:

    T12-L1: No significant disc herniation, central stenosis or
    neural foraminal narrowing.

    L1-L2: No significant disc herniation, central stenosis or neural
    foraminal narrowing.

    L2-L3: Facet arthropathy. No significant disc herniation, central
    stenosis or neural foraminal narrowing.

    L3-L4: Facet arthropathy. No significant disc herniation, central
    stenosis or neural foraminal narrowing.

    L4-L5: Severe facet arthropathy with fluid signal within the
    bilateral facet joints as well is a small, tiny 1 mm left
    intracanalicular synovial cyst result in mild bilateral neural
    foraminal narrowing, as well as borderline mild central stenosis.

    L5-S1: Facet arthropathy. No disc herniation, central stenosis or
    neural foraminal narrowing.

    SACRUM: No significant abnormality seen.

    Miscellaneous: Paraspinal muscles are unremarkable. Subcentimeter
    probable right renal cyst. Status post cholecystectomy. 7 mm
    rounded T2 hyperintensity in the mid abdomen adjacent to the
    liver seen on scout images (series one image 4) which may
    represent volume averaging with bowel, but is incompletely
    imaged.

    IMPRESSION:
    1. Severe L4-L5 facet arthropathy with mild bilateral neural
    foraminal narrowing and borderline mild spinal canal stenosis

    Report Status: Final
    Type: Lumbosacral Spine Min 4 Views
    Date/Time: 06/13/2013 12:18
    Exam Code:
    Ordering Provider:

    HISTORY:
    Backache –

    REPORT AP, Lateral and Bilateral Oblique Views of the Lumbar Spine

    COMPARISON: None.

    FINDINGS:
    There is anterolisthesis of L4 on L5 which measures 7 mm in flexion
    and 4 mm in extension. Vertebral body heights are maintained. There
    are mild endplate degenerative changes. Facet degenerative changes
    from L3-S1.

    There are bilateral sacroiliac joint degenerative changes. Surgical
    clips are noted in the right upper quadrant consistent with prior
    cholecystectomy.

    IMPRESSION:
    Anterolisthesis of L4 on L5 with increase in flexion as above.
    Associated facet degenerative changes. Posterior elements appear
    intact.

    ***

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    Your X-ray and MRI reports point to the L4-5 level as potentially the most symptomatic level of your lumbar spine. You have a degenerative spondylolisthesis of L4-5 (see website for explanation) with foraminal stenosis.

    Your radiologist notes; “L4-L5: Severe facet arthropathy with fluid signal within the bilateral facet joints as well is a small, tiny 1 mm left intracanalicular synovial cyst result in mild bilateral neural foraminal narrowing, as well as borderline mild central stenosis”.

    “There is anterolisthesis of L4 on L5 which measures 7 mm in flexion and 4 mm in extension. Vertebral body heights are maintained. There are mild endplate degenerative changes. Facet degenerative changes from L3-S1”.

    Facet arthropathy is typical with a degenerative spondylolisthesis as the facets have to break down to allow the upper vertebra to slip on the lower vertebra. The MRI picture is generally not conclusive for this disorder as the MRI image is gained with the patient supine (lying down). Gravity then reduces the slip so the slip appears much less than what is really is. The facets distract (separate) with lying on the back so the MRI image notes much fluid in these joints; “fluid signal within the bilateral facet joints” but less slip.

    The foraminal stenosis noted on the MRI is underestimated due to the shift of the vertebra back to a more normal association with it’s neighbor. This is why the standing X-rays with flexion and extension views are so important to complete the diagnostic picture. Your X-ray report notes a shift from 4mm to 7mm with bending forward and backwards but the radiologist does not discuss any slip with the MRI.

    The MRI data is helpful as this slip amount with lying down can be compared to the total slip amount with flexion (in your case to 7mm) to give a more accurate total slip measurement. You have a total of 3mm of motion on the standing X-ray films which is enough to give you a diagnosis of instability at this level but I bet the slip amount is even greater when you compare the MRI with the flexion X-ray.

    This is significant enough to cause your symptoms.

    Dr. Corenman

    Littleshell09
    Member
    Post count: 7

    Thank you for the response. I’m wondering if surgical intervention might be warranted? I’m really uncomfortable most of the time & unable to engage in activities which previously added to my quality of life. My legs hurt badly when climbing stairs, sleep is interrupted, etc. Physical Therapist suggested I should seek surgical consult as movement was so difficult. The lumbar area “catches” & I can’t move. My family is tired of seeing their once active mom so limited. I had a recent problem with my R knee & the Ortho felt the back may be lending to that syndrome as well. I feel grateful for your thoughts.
    Respectfully,

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    Surgery can be warranted. See the section on this website “When to have lower back surgery” to understand when surgery is indicated.

    You might need some further diagnostic testing before you have someone recommend surgery. This might be further imaging as I noted before or epidurals with a pain diary (see website).

    Dr. Corenman

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