[Liliana]

#8741

First off, Dr. Corenman, I just want to say that your site and videos have been extremely helpful in understanding what’s going on in my spine, and helping to give me more confidence when working with my doctor and specialists. Thank you.

I have searched all over, and I am having trouble finding information about some of the things mentioned in my latest Lumbar MRI. I am in that great stage of limbo called ‘waiting for the appt to the spine specialist’, so I’m trying to use my time wisely and make sure I’m fully prepared for my appt, and have a better understanding of what’s going on. I am told they will probably do xrays, but I don’t know what they’d be looking for that didn’t show up on the MRI.

I have had back issues since 2003, and 5 MRIs since then, the latest being a few weeks ago. They have showed pretty steady degeneration, but things have gotten worse lately, and I think the MRI shows it. I also have Ehlers-Danlos Syndrome Hypermobility Type (a connective tissue disorder – I’m very bendy and have joints that dislocate or sublux), and bilateral hip dysplasia. I have been told before that I was not a candidate for surgery, but as things have progressed, I want to make sure nothing is overlooked to be able to get help with this. I’ve had many years of PT, a soft band/brace, epidural shots (did not help), and too many medicines over the years. Until about a year ago, I walked with forearm crutches to help with pain and hip dislocations, but after years of that, I developed shoulder dislocations, so that is no longer an option.

Here’s the MRI from this month. There are many phrases in here I’ve never seen, or at least never seen in my previous reports.

Findings:
Five lumbar-type segments are assumed, S1 is a trapezoidal shaped vertebral body, there are minimal partial lumbar features suggested on the right. There is a small S1-S2 disc. Inferior tip of the conus medullaris is positioned at the interior L1 level. There is a L1 cavernous hemangioma. Focal marrow fat versus a small cavernous hemangioma is present at L3. There is slight dextroscoliosis, apex at approximately the L4 level.

There is a decrease in T2 and STIR disc signal at the L3-L4 through L5-S1 levels, decrease in the disc height is also present at the L4-L5 and to a lesser degree L5-S1. No spondylolysis or significant spondylolisthesis is seen.

At the T10-T11 through L1-2 levels, the central spinal canal neural foramina are adequate on sagittal views. There are minimal disc bulges.

At L2-L3, there is a minimal disc bulge. The central spinal canal and neural foramina are adequate. There is a slight prominence of facet joints and ligamenta flava.

At L3-L4, there is disc bulge. A central and right paracentral annular fissure is present, disc is contained by the posterior longitudinal ligament complex. Minimal subligamentous extension of disc along the posterior aspect of L4 suggested. There is mild effacement of the ventral thecal sac, no significant central spinal canal stenosis or significant neural forament encroachment is seen. The left neural foramen is mildly narrowed. Facet joints and ligamenta flava are mildly prominent, there is slight facet degeneration.

At L4-L5, there is diffuse disc bulge, superimposed, there is a broad-based left lateral and far left lateral disc protrusion – osteophyte plaques versus asymmetric left sided disc bulge. There is a mild relative narrowing of the central spinal canal without significant central spinal canal stenosis. Lateral recess narrowing is present at the on the left without marked encroachment on the region of the L5 nerve root. There is moderate narrowing of the left neural foramen. Correlate for L4 and/or L5 radicular findings. The right neural foramen is mildly narrowed.

At L5-S1, there is there is a right paracentral and lateral broad-based disc protrusion. This effaces the ventral aspect of the thecal sac centrally and on the right. There is blurring of perineural fat at the ventral-medial margin of the right S1 nerve root, correlate for right S1 radicular findings. This finding is not described on the prior report (prior outside lumbar sine MRI report from Polyclinic dated 12/14/20058 describes centralized disc bulge without any effect on nerve roots L5-S1). Correlate for possible right S1 radicular findings. Neural foramina are mildly narrowed without significant encroachment seen on the exiting L5 nerve roots. There is mild facet degeneration.

Visualized paraspinal muscles appear unremarkable. There is a nonspecific subcutaneous dependent edema signal.

There is fluid signal in mildly prominent small bowel (up to 2.4 cm in diameter), projecting to the left of the left psoas muscles at the L3-L4 level. Other visualized small bowel is nondilated. This lumbar spine MRI study is not a diagnostic evaluation of the small bowel. Suggest correlation.

Impression:
1. Right paracentral and lateral disc protrusion at L5-S1 with some mild effacement of the right S1 nerve root, correlate for possible right S1 radicular findings. Findings are superimposed on degenerative disc disease at this level.
2. Degenerative disc disease at L4-L5, there is an annular fissure component. The left neural foramen is moderately narrowed. There is some lateral recess narrowing. See discussion in the Findings section.
3. Degenerative disc disease at L3-L4 with disc bulge, a small annular fissure is present. No significant encroachment on the neural structures identified.

If it helps, here is my report from 2008:
At T12-L1, mild bulging annulus and facet hypertrophy.
At L1-2, mild bulging annulus and facet hypertrophy.
At L2-3, mild bulging annulus and facet hypertrophy. There is a small disc bulge into the left foramen without any definite effect on the nerve roots. There is a signal change in the L1 vertebral body suggestive of a benign vertebral hemangioma.
At L3-4, there is a mild broad-based disc bulge with facet and ligamentous hypertrophy. There is mild foraminal stenosis. There is mild central canal stenosis.
At L4-5, there is a mild broad-based disc protrusion. There is facet and aligamentous hypertrophy. There is mild foraminal stenosis bilaterally and mild central canal stenosis.
At L5-S1, there is a centralized disc bulge without any effect on nerve roots. There is facet hypertrophy present. There is a mild foraminal stenosis bilaterally. Sacrum appears grossly intact.

And one from 2005, to show progression:
At L1-2, disk height and signal appear well preserved, with no evidence of significant disc herniation or stenosis.
At L2-3, disk height and signal appear well preserved, with no evidence of significant disc herniation or stenosis.
At L3-4, there is a disc desiccation, though disc height is well preserved. Mild circumferential disk bulging has not changed significantly in the interim, though the posterior anular tear does appear more conspicuous. No evidence of significant central canal or foraminal stenosis.
At L4-5, the disc is desiccated, with minimal disc height suggested. This has not changed significantly in the interim. Mild increase in the circumferential disc bulging is suggested, with greater conspicuity of central canal or foraminal stenosis.
At L5-S1, there is a disc desiccation and mild interim loss of disk height. New small posterior central broad-based disc protrusion does not cause significant central canal or foraminal stenosis. It does not appear to cause mass effect upon the descending S1 nerve roots. Moderate bilateral degenerative changes of the facets have not changed significantly.

Any insight to the latest reading or anything that sticks out as something I should make sure to ask the specialists about, would be so helpful. Thank you again.

[Donald Corenman, MD, DC]

#8745

First- patients with Ehlers Danlos disorder that have subluxing hips and shoulders can undergo stabilization surgery to prevent these subluxations. If you can’t walk, this is one of the first problems to be addressed.

You do not explain your symptoms in terms that are diagnostically useful. See the section “How to describe symptoms” to understand how to explain in diagnostic terms what you are experiencing. Do you have more leg pain or more back pain and by what percentages? Standing or sitting pain?

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.

[Liliana]

#8751

Thank you for your reply. My history of spine involvement goes back a ways, so I’ll try to get out what are (hopefully) the most important and useful parts.

I first sought help for my lower back pain in 2003 after NSAIDs and exercises weren’t helping. It started out as a sharp pain in the middle and slightly to either side of my back, about 2″ above my buttocks. After my MRI, they said there was disc damage, but that the pain would go away if I lost weight. I was 250lbs+ (at 5’2″). So that year I got gastric bypass (for my back and for other health reasons) and lost over 100lbs. I became more mobile and was able to walk more and get around. My back got considerably worse after about a year. I started using a cane, then two canes (my PT didn’t want me to favor any one side), then forearm crutches. It helped my back a lot, pain-wise, but was very hard on the rest of my body. I have a small folding cane I keep with me for emergencies, but other than that, I cannot use anything to get around with because of my shoulders. I have since gained back about 30lbs, and I know this does not help with bone/joint issues, but I can only get around so much with this pain. I have kept the same weight for about 5 years, but I feel like if I was in less pain, I’d be able to get down to a healthier weight and help my back out even further.

Also of note, is that in 2007, my legs started swelling (mostly the right), but didn’t pit until this year. I’ve had many tests to make sure it’s not clots or the like, but there’s been no definite answers to it. I fell on my tailbone in the kitchen off a stool 2 months after the edema started and it got worse. I mention this because since the last ‘shift’ in my back and the nerve pain got worse and changed position, for the first time since this started, the edema in my legs is going down. It’s still there, but my left leg is almost normal, and my right leg has gone down considerable. I don’t know if it related, but I thought I’d mention it because you never know.

There are a few different kinds of pains that I deal with from my back. One, I’ll call the ‘regular’ pain, it’s there most of the time. It’s in the center of my lower back, just a few inches up from the gluteal cleft. It’s a ache, sometimes sharp, and the area is painful to the touch, or with light pressure. It’s about 80% back and 20% leg, as the pain sometimes refers down. I’ve had it for a while. It also runs between 4-8 on the pain scale, and seems to do a bit better with a heating pad, NSAIDs, and percocet.

The second one is called the ‘bad’ pain. It’s horrific blinding pain that seems to start at even the smallest of motions (as opposed to falling or lifting something heavy). I don’t know how to make this pain go away, but it is much worse when moving my core or trying to raise my leg (mostly right leg). It’s a severe, and deep ache, with sharp stabs too. It’s about 100% back (with rare pain down a leg if I move), and it rarely goes away. The pain is pretty consistent too, and at 8-10 on the pain scale. It isn’t helped with medications. Occassionally. that pain can be dulled down by heat, or (when I’ve had one) a TENS unit. It lasts about a week or so with extreme pain, and when it does start to subside, it can be brought back instantly with a slight wrong movement for a few weeks.

The third pain, is the ‘new’ pain. It started in the last few months, and things have changed significantly. My back has always been ‘loose’, it shifts and clicks with the slighted movement. The only exceptions with that is when my back sort of goes into ‘lock down mode’ when I’m having a lot of pain. This pain seems more independent to the others (in that pain is different and has different triggers), and is centered more around the nerve that goes from the lower right side of my back over the buttock, and slightly down my right leg. I would say 90% buttock, 10% back. It has the sharp twinge that if I bend, sit, cough, move wrong, or even tilt my head down, it feels like a cattle prod touched my backside. It’s usually worse in the morning, and a little less temperamental at the end of the day. This pain is the only one where, when it’s not hurting really bad, is almost pain free. So on a pain scale, it’d be 0-9, 9 being where it feels like electric shocks are going through me. If I do manage to ease into a sitting position, when I stand back up, the pain shoots through the right buttock area and it feels like a muscle cramp is around it.

In general though, I have some kind of back pain 24/7. At best, it’s a minor annoyance and can be controlled with pain meds, and at worse, it’s completely debilitating and I cannot perform daily functions at all, or need considerable help. I don’t think I have a limp or anything, but for years, the toe area of my right shoes always wear down first. I cannot bend backwards, even slightly, without significant pain, and when the new nerve pain hits, I cannot bend forwards or sit without pain and difficulty.

I used to be a hairdresser, but retired after multiple injuries and degenerative changes made it to painful. I became a receptionist after that, but sitting and lifting small things (carrying mail, large file folders, putting things on shelves) made things uncomfortable too. I would love nothing more than get a hold of this pain and take my life back.

I hope this info is more useful. I will be bringing this info with me to the specialist when I go too, so if there are any missing pieces, don’t hesitate to ask me about them.

Thank you again for your response.

[Donald Corenman, MD, DC]

#8756

First-lower back pain can improve with weight loss but it is not a given. I treat athletes from all sports who are thin and trim and these individuals have the same back pain that you have.

Second, leg swelling is generally not related to lower back pain. This has more to do with metabolic or circulatory disorders like venous incompetence, heart disorders or kidney problems.

Your deep, dull pain sounds like degenerative disc disease. Your “horrific blinding pain” sounds more like instability pain. Buttocks pain could be from newer nerve involvement. With Ehlers Danlos Disorder, the ligaments will be more lax allowing more of a “shift” of one vertebra on the next. This shift can impinge upon the nerve. Mild impingement will radiate only down to the buttocks.

You noted in an earlier post that you needed crutches for your subluxing hips. In this post, the canes were more for your lower back pain. What reasons do you need the crutches for, back or hip pain?

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.

[Liliana]

#8759

I started using a crutch to help with the lower back pain and getting around. About a year after that, I started using 2 crutches because the instability of using just one was causing my hips to sublux easier. In 2009, I started using forearm crutches to take the strain off my hands/wrists (as opposed to the canes). I was using the crutches for both back pain and to create stability when my (mostly right) hip would easily slip from where it was supposed to be and create instability.

I do not use them anymore, except in emergencies, as of a year ago, because of reoccuring should subluxing and discloations (that were said to have been aggravated by using the crutches). I have done intense PT to get my core muscles stronger and help with the pain of getting around. My hips are still unstable, as are my shoulders, but I know that sometimes with EDS there are just things you have to deal with. The back and related nerve pain though, I cannot handle and cannot get the pain levels to an acceptable level to function and hold a job outside the home.

I will also say that my EDS wasn’t dx’d until 2006 (by a geneticist), and all related problems before then were attributed to weight, or that it was all in my head (“You can’t possibly have had your kneecap dislocate from someone leaning on it.” when I was in the ER), and that my back wouldn’t get worse because I was so young (I’m 38 now) and most PT people would always focus on trying to make me more flexible instead of helping me control my body more. Some even freaked out that some of my joints were too loose and why wasn’t I feeling the appropriate pain from them? :( I had chiropractic care for a while, which initially helped, but the last instance in 2006 left me with 2 additional bulges and a herniation (thoracic level), so I will not go again.

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