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Hello Dr. Corenman,
First off I want to thank you for your time and help in what you do for people.
I was hoping you could help me better understand my CT Findings.
Past and current history of symptoms;
Lower back pain off and on for approximately 20 years. This latest onset of pain started 11 months ago consisting of moderate to severe lumbar pain and radiating painful right sciata pain from R lumbar to ankle daily. The pain has progressively worsened over time and now experiencing numbness and tingling from right calf to foot when sitting,driving, coughing. Difficulty putting weight on right foot after sitting for short periods. Recently started feeling more pain in Left lumbar with periodic sharp shooting pain in lumbar and right front center of pelvis.
Treatment
Chiropractor x 3 visits 3 months ago
1 medrol pack (1 day relief mid dose)
1 cortisone injection which did nothing for painCT and Xray findings as follows:
EXAMINATION: CT SCAN OFLUMBAR SPINE WITHOUT CONTRAST Clinical history: Low back pain with right sided sciatica
FINDINGS:
Lumbar lordosis appears exaggerated. Intervertebral disc height is reduced at L5-SI with vacuum phenomena, endplate sclerosis anteriorly end plate bony spurs. All the lumbar vertebral bodiesLI L2: No significant neuroforarninal narrowing or spinal canal stenosis.
L2 L3: Diffuse disc bulge noted indenting thecal sac. No significant neuroforaminal narrowing.
L3 -L4: Diffuse disc bulgc noted with superimposed left foraminal disc hemialion sagital image 33/54 causing some narrowing of left neural foramen.
L4-L5: Asymmetrical disc bulge noted with left foraminal disc herniation causing some narrowing of left neural foramen inferiorly sagittal image 33/54
L5 SI: Grade l anterior listhesis of L5 over S1 by 3.6 mm with sclerosis at pars interarticularis (on the left) showing cortical step off without definite discontinuity Right far lateral/foraminal disc protrusion herniation with bony spur sagittal image 19/54 corresponding to axial image 5/17 severely effacing right lateral recess impinging on right traversing nerve root and causing moderate narrowing of right neural foramen.
Pre-and paravertebral soft tissues including the visualized abdominal aorta and bilateral kidneys appear unremarkable.
XRAY OF LUMBAR SPINE WITH FLEXION AND EXTENSION
FINDINGS:
Lumbar lordosis exaggerated
Intervertebral disc space is reduced at L5-S1 with endplate bony spurs.Grade 1 anterior listhesis of L5 over S1 noted.
Facet joint hypertrophic changes are noted at L4/L5.
On flexion and extension views no changes noted in the severity of anterior listhesis of L5 over S1. At rest of the lumbar levels no instability noted.
Visualized soft tissue shadows appear unremarkable.
IMPRESSION:
l. Grade 1 anterior listhesis of L5 over S1 with reduced intervertebral disc space
My surgeon quickly looked at the film’s only as he had not received the report and said no slippage or pars fractures. He said surgery is needed with 2 options dependent on how much time I could afford to be out of work.
A. Full cage? This would alleviate both lumbar pain as well as sciatic pain and compression. 3 months out of work.
B. Microdistectomy with partial fusion on left side utilizing salvageable bone from my right side and possibly cadaver bone and doing a non hardware fusion to my left side for better stability.
I’m a 48 years old female and very scared that I may not be able to perform my job in the medical field as it requires some manual labor and driving. Do you agree with the recommended treatments my surgeon has given?
Hello Dr. Corenman,
First off I want to thank you for your time and help in what you do for people.
I was hoping you could help me better understand my CT Findings.
Past and current history of symptoms;
Lower back pain off and on for approximately 20 years. This latest onset of pain started 11 months ago consisting of moderate to severe lumbar pain and radiating painful right sciata pain from R lumbar to ankle daily. The pain has progressively worsened over time and now experiencing numbness and tingling from right calf to foot when sitting,driving, coughing. Difficulty putting weight on right foot after sitting for short periods. Recently started feeling more pain in Left lumbar with periodic sharp shooting pain in lumbar and right front center of pelvis.
Treatment
Chiropractor x 3 visits 3 months ago
1 medrol pack (1 day relief mid dose)
1 cortisone injection which did nothing for painCT and Xray findings as follows:
EXAMINATION: CT SCAN OFLUMBAR SPINE WITHOUT CONTRAST Clinical history: Low back pain with right sided sciatica
FINDINGS:
Lumbar lordosis appears exaggerated. Intervertebral disc height is reduced at L5-SI with vacuum phenomena, endplate sclerosis anteriorly end plate bony spurs. All the lumbar vertebral bodiesLI L2: No significant neuroforarninal narrowing or spinal canal stenosis.
L2 L3: Diffuse disc bulge noted indenting thecal sac. No significant neuroforaminal narrowing.
L3 -L4: Diffuse disc bulgc noted with superimposed left foraminal disc hemialion sagital image 33/54 causing some narrowing of left neural foramen.
L4-L5: Asymmetrical disc bulge noted with left foraminal disc herniation causing some narrowing of left neural foramen inferiorly sagittal image 33/54
L5 SI: Grade l anterior listhesis of L5 over S1 by 3.6 mm with sclerosis at pars interarticularis (on the left) showing cortical step off without definite discontinuity Right far lateral/foraminal disc protrusion herniation with bony spur sagittal image 19/54 corresponding to axial image 5/17 severely effacing right lateral recess impinging on right traversing nerve root and causing moderate narrowing of right neural foramen.
Pre-and paravertebral soft tissues including the visualized abdominal aorta and bilateral kidneys appear unremarkable.
XRAY OF LUMBAR SPINE WITH FLEXION AND EXTENSION
FINDINGS:
Lumbar lordosis exaggerated
Intervertebral disc space is reduced at L5-S1 with endplate bony spurs.Grade 1 anterior listhesis of L5 over S1 noted.
Facet joint hypertrophic changes are noted at L4/L5.
On flexion and extension views no changes noted in the severity of anterior listhesis of L5 over S1. At rest of the lumbar levels no instability noted.
Visualized soft tissue shadows appear unremarkable.
IMPRESSION:
l. Grade 1 anterior listhesis of L5 over S1 with reduced intervertebral disc space
My surgeon quickly looked at the film’s only as he had not received the report and said no slippage or pars fractures. He said surgery is needed with 2 options dependent on how much time I could afford to be out of work.
A. Full cage? This would alleviate both lumbar pain as well as sciatic pain and compression. 3 months out of work.
B. Microdistectomy with partial fusion on left side utilizing salvageable bone from my right side and possibly cadaver bone and doing a non hardware fusion to my left side for better stability.
I’m a 48 years old female and very scared that I may not be able to perform my job in the medical field as it requires some manual labor and driving. Do you agree with the recommended treatments my surgeon has given?
I failed to include that he said option B microdistectomy would only put me out of work for 3 weeks and that it would relieve the sciatica pain but may not relieve all my lumbar pain.
Thank you very much for your time and input!
You have a dysplastic isthmus spondylolisthesis of L5-S1. This is a variant of the standard isthmus spondylolisthesis where instead of a one time fracture that does not heal, in the dysplastic variant the pars fractures and heals multiple times and actually elongates. This still allows the slip of L5 on S1 by elongating the pars. The pars appears abnormal but intact on a CT scan (“sclerosis at pars interarticularis (on the left) showing cortical step off without definite discontinuity”).
You must have misunderstood the surgeon as there appears to be obvious slippage by report and he would not miss that.
Do not do any fusion surgery that does not have instrumentation (screws and rods). It has been proven over and over that the “in situ” (no hardware) fusions are much less effective and fusion rates are poor. You need the typical TLIF surgery (if indeed you are a surgical candidate but I assume you have failed conservative measures and your symptoms fit the pathology).
With a job description, I cannot comment on how long you might be out of work. Even with this information, different surgeons have varied post-operative restrictions. I could only give you my advances in activity based upon the surgical operation.
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.Thank you very much Dr. Corenman for your advice and feedback. Duly noted and I will not go the non hardware route. I did have a second cortisone injection last Tues. as the first one (4 weeks prior) did nothing. This one has alleviated some of the sciatic pain but still have tingling from calf to bottom foot and lumbar pain on both right and left side now. Conservative treatments have been chiropractic therapy, medrol pack, 2 cortisone injections. No physical therapy was ever ordered. Would physical therapy improve my situation?
I spoke to the scheduler while I was there and asked what the exact procedure was that he was planning. His diagnosis and surgical orders are as follows;
Diagnosis
Displacement of Lumbar Intervertebral Disc without MyelopathyProcedure
Have ISTOS and bone allograft chips graft ready.
L5-S1 right sided hemilaminectomy with facectomy: Distectomy at L5-S1: Non-instrumented fusion of L5-S1: Iliac crest bone marrow aspirationApparently I did misunderstand about the slippage but he was in between surgeries when he went over my CT films with me and was rather quick to explain. Possibly he said the slippage wasn’t as bad as what he was seeing on the MRI…
I have scheduled an appointment with a Neuro here where I am located to go over my films and give his suggestions as well. I wish I lived there so I could come to you! My employer is getting close to putting me on short term disability due to my work duty restrictions.
I’m very confused, scared, and extremely stressed about all this. I just can’t imagine living in this pain for the rest of my life. Any other advice you can give would be greatly appreciated!!
Thank you!!
Another opinion would be helpful. The surgeon is planning an in-situ fusion (fuse in place without instrumentation) which has a much lower fusion success rate.
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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