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  • ol99
    Participant
    Post count: 14

    Hi Doctor Corenman,

    I (32M) have an issue that might be interesting to investigate.

    Almost a year ago I injured my back while doing deadlifts – had mild, tolerable pain in the left buttock and back of the thigh.

    9 months ago, while doing PT, I was lying on my stomach in maximum back hyperextension and pulled my left leg to the side of my body. Immediately I felt sharp pain in the right side of my low back (slightly latteral from the right S1 nerve root, maybe facet location).

    A few days later my right leg, felt slightly numb/altered in sensation in the region from the knee to the foot. I did an MRI which showed a broad 6.5mm central-paracentral-foraminal left protrusion on L5S1, with isthmic spondylolisthesis, slight instability, bilateral pars defects, DDD, and an annular tear on the same level.

    EMG showed compression on the left S1 nerve, and small radiculopathy on the right S1 and left L5.

    I received a diagnostic nerve block in both S1 nerves. The left leg started feeling a lot better, while I felt no improvement in the right leg, and only felt minor improvement in the right side of my low back.

    Eventually, 6 months later I started having muscle weakness in the left calf and had an endoscopic discectomy.

    Now, 3 months later the left leg is much better, but there is almost no change in my right leg.

    A new post-op MRI shows the same things as pre-op, just that the protrusion at L5S1 is smaller.

    The pain I have originates from the right part of my low back (around the facet probably) and is focused in my right knee. If I try to do back extensions or try to hang from a pull-up bar, the pain increases in intensity and expands to my right foot.

    If I try to do a quick flexion-extension movement, I get a lot of pain in the back of the right thigh.

    If I try to side-bend to the right, I get pain in the small toe in the right foot (despite not having any herniation). This was true before and after the surgery.

    I noticed that if I try to walk with my back flexed, all the pain goes away from my right leg, and I start to have a gait issue with the left one. Conversely, if I try to walk while extended, my right leg pain increases, and I develop a gait problem in the right leg.

    Sitting also helps with my right leg and back symptoms, while lying down with the legs straight can be painful.

    The question is, what is my pain generator?

    I would opt for some kind of fusion, but it’s hard to do so without knowing for certain if my spondylolisthesis or facets are causing it. I guess I somehow injured both my disc and some bony part of my spine while doing the PT hyperextension with the leg to my side. Perhaps I now have some kind of weird lateral and flexion-extension instability on the L5S1 level along a wide a broad protrusion which irritates different nerves in different positions.

    ol99
    Participant
    Post count: 14

    Also forgot to add the MRI shows facet hypertrophy at L5S1, the same level as the other pathologies.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    You note a “6.5mm central-paracentral-foraminal left protrusion on L5S1, with isthmic spondylolisthesis…EMG showed compression on the left S1 nerve, and small radiculopathy on the right S1 and left L5”. “Eventually, 6 months later I started having muscle weakness in the left calf and had an endoscopic discectomy”.

    “Now, 3 months later the left leg is much better, but there is almost no change in my right leg…The pain I have originates from the right part of my low back (around the facet probably) and is focused in my right knee. If I try to do back extensions or try to hang from a pull-up bar, the pain increases in intensity and expands to my right foot. I noticed that if I try to walk with my back flexed, all the pain goes away from my right leg”.

    You have classic foraminal stenosis due to isthmic spondylolisthesis causing L5 radiculopathy. Since the foramen narrows with standing and enlarges with sitting or flexion, leg pain is worse with walking and improved with sitting or bending forward.

    See:
    https://neckandback.com/conditions/isthmic-spondylolisthesis-slipping-of-a-vertebra-because-of-fracture/
    https://neckandback.com/conditions/foraminal-collapse-lumbar-spine/

    Dr. Corenman

    ol99
    Participant
    Post count: 14

    Thanks for the articles, I gave them a ready and understand a lot more now.

    Question: I’ll get a flexion-extension xray today since I’ve never had one. Would there be any value in making a CT?

    Because it seems the foraminal/facet pain is mostly in the right side, perhaps I’ve made some kind of tear in the pannus, so not sure how to diagnose that. The MRI (supine) itself doesn’t show foraminal stenosis, so it might be minor.

    Also, would an OLIF/ALIF address all of these pathologies, since it seems those procedures don’t remove the facets and other bony stuff?

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    An OLIF, ALIF or TLIF would decompress the nerve root, stabilize the pars fractures and most likely stabilize the segment and significantly reduce the pain. Either an ALIF or OLIF would have to be “backed up” posteriorly with pedicle screws while a TLIF would by definition have pedicle screws placed as part of the procedure.

    Dr. Corenman

    ol99
    Participant
    Post count: 14

    Yeah, the doctor said that any fusion I would have must have screws because of the pars fracture.

    Last question (curious since I always follow the advice from your articles): The disc above my problematic segment looks almost OK. Two radiologist readings (1.5T MRI) didn’t find anything, one (3T MRI) notes bulging and the standing xray says it has discopathy.

    I opened the MRI, and could see normal (bright) signal intensity, apart from a darker color in the left sagittal slice. My L5S1 is herniated on the left, so maybe it’s related.

    Should I potentially include that L4L5 disc in the fusion? The surgeon said it’s not okay to preventively fuse discs, especially in younger patients. I’m just scared in case that disc is symptomatic and I find that out after surgery…

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