[wmiller]

#31609

Hello, Dr. Corneman. I’m going to paste below the findings of two MRIs. One was done in June, right before I had an urgent right L5/S1 discectomy, and the other was Nov. 14. Background

-I had complete resolution of symptoms after the surgery in June.
-In sept./October began having left-sided LBP that went down leg, mostly lateral. It is much worse with walking, better with sitting/bending forward. Walking for more than 10 minutes is nearly impossible due to pain in back/down leg and into ankle.
-I had PT for a month before an MRI was ordered. About four days AFTER the MRI, I began having identical, but less severe, symptoms on the right side–so I’m not sure this MRI is representative of those.
-I saw surgeon today, and he said that he didn’t see anything in my MRI that points to exactly where the pain is coming from (and while it’s not as bad as my herniation in June), it keeps me from living a normal life. He suspects there is a small reherniation affecting S1 that is not caught on MRI, but I have an EMG saying that L5 is what is the culprit. He says the MRI doesn’t indicate that L5 could be causing these symptoms, as the stenosis from the bulging disc is just “moderate” and I’m in significant pain. I had none of this pain when my June MRI was done. I’m pasting both MRIs for comparison (only the abnormal parts):

JUNE 2019 MRI:
L4-L5: There is mild, broad posterior bulging of the disc with a
small circumferential annular tear in the posterior disc margin. Mild
facet and ligamentum flavum hypertrophy are present. There is no
significant foraminal stenosis or mass effect on the exiting L4 nerve
roots. The L5 nerve roots are contacted in the lateral recesses but
do not appear compressed.

L5-S1: A large disc herniation arises from the midline and extends
into the right lateral recess, displacing and compressing the right
S1 nerve root. The herniated fragment measures approximately 1.8 cm
sagittal by 1.3 cm transverse by 0.8 cm AP. Mild disc bulging and
disc space narrowing results in mild bilateral foraminal stenosis but
the L5 nerve roots are not compressed.

NOVEMBER 2019 MRI:
L4-L5: There is shallow posterior bulging of the disc with mild
facet and ligamentum flavum hypertrophy. There is mild bilateral
foraminal encroachment and moderate lateral recess stenosis greater
on the left. The L5 nerve roots are contacted and the left L5 nerve
root may be slightly compressed.

L5-S1: There has been partial hemilaminotomy on the right. There is
enhancement in the surrounding soft tissues. There is a small amount
of fluid in the right facet joint. The herniated disc fragment noted
on the previous study has largely been resected. Mild posterior
bulging of the disc persists. There is mild bilateral foraminal
stenosis without evidence of nerve root impingement on either side.

[Donald Corenman, MD, DC]

#31616

First you have to remember that I am looking at the MRI’s from the radiologist’s perspective so some information is lost.

In June, you had a large extruded HNP compressing the S1 root. That was obvious. In November, you had somewhat more significant left L4-5 lateral recess stenosis which would compress the left L5 nerve root. You do have “mild” foraminal stenosis bilaterally. This also could compress the left L5 root.

Your pain is stenotic in nature, worse with standing and better with bending (“It is much worse with walking, better with sitting/bending forward”). Stenotic pain is associated with both lateral recess stenosis and with foraminal stenosis which fits with both levels.

I would note that you probably could benefit from a small volume transforaminal epidural steroid injection at L4-5 left and then on a separate day, a selective nerve root block at L5-S1 left. Keep a pain diary to determine which level is more significantly involved.

See https://neckandback.com/treatments/epidural-injections-and-selective-nerve-root-blocks-diagnostic-and-therapeutic/
https://neckandback.com/treatments/pain-diary-instructions-for-spinal-injections/
https://neckandback.com/treatments/diagnostic-vs-therapeutic-injections/

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.

[wmiller]

#31623

Thank you. I had my injections yesterday, and he did something similar to what you suggested. He first numbed S1 (no steroid). After about 2-4 minutes they had me try to walk around and see how it felt. The back pain was no better, and I could still elicit the leg pain. So then he did the same with L5. I had some reduction in the back pain (but not all) and complete resolution of the leg pain (even touching where I usually have the pain was completely numb). So he put a steroid at L5 on both sides. He feels sure it is L5 because of this and because my EMG indicates L5.

Is it normal for the injection of numbing medicine not to totally remove the back pain? He told me the remaining pain I was feeling there was from the disc itself, as he only injected at the nerve root. I am hoping that the steroids I had will calm not just the leg pain, but back pain also.

[Donald Corenman, MD, DC]

#31630

Back pain generally is generated by disc and occasionally facet so epidurals might not yield full back pain relief. Leg pain is generally nerve root mediated so a block should give temporary relief as long as it is the correct nerve numbed.

Your L5 nerve seems to be the inflamed nerve but as I noted earlier, can be compressed at the L4-5 level in the lateral recess or the L5- S1 level at the foramen. The injection correctly identified the correct nerve (L5) but was not specific enough to identify the compressive location.

Steroids can sometimes allow long term relief of back 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.

[wmiller]

#31651

Thanks. I’m not sure if he did both levels for L5. I sent a message to ask.

I am confused about surgical options (which I hope i don’t need) for foraminal and recess stenosis caused by a bulging, but not herniated, disc. A laminectomy to decompress would not get rid of the bulging disc, correct? So if it herniated I would get a discectomy (and they told me it’s very stretched and close to herniating, but trying to prevent), but if I cannot get sustained relief from injections and PT, how would stenosis be treated if the main cause was a bulging disc?

[wmiller]

#31657

wmiller wrote:

Thanks. I’m not sure if he did both levels for L5. I sent a message to ask.

I am confused about surgical options (which I hope i don’t need) for foraminal and recess stenosis caused by a bulging, but not herniated, disc. A laminectomy to decompress would not get rid of the bulging disc, correct? So if it herniated I would get a discectomy (and they told me it’s very stretched and close to herniating, but trying to prevent), but if I cannot get sustained relief from injections and PT, how would stenosis be treated if the main cause was a bulging disc?

As an update: they called me back and said he did L5/S1 only bilaterally and that the medicine would “move up and down levels.” I don’t understand how a trans foraminal injection can affect multiple levels at once. Is that even possible? I’ve had no relief after 4 days. If this continues, i should ask for an L4/L5 injection? At this point I’m ready to come to Vail!

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