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  • HezWag
    Member
    Post count: 2

    Hi Dr Corenmen,

    I have a few questions hopefully you can help me with. I have had this back pain since an injury at work on April 26th of this year. I have undergone about 4 months of PT, have had 2 ESI’s, and I am still in constant pain. I have metal in my chest so they will not do an MRI, however I have had a CT scan in June that showed a 1mm herniation at L4-L5 and a 4mm herniation at L5-S1. I have experienced non-stop horrific pain in my back as well as in my left buttocks going down my left leg. Originally I did not have any weakness, but this has developed in my left leg for the last 2 months. I did not receive much reduction in pain from the epidural steroid injections. From the 1st injection I did get minimal relief in the leg pain for about 1 week. Since the second injection I have had an increase in pain as well as a non-positional headache for the last week. Is this a normal occurance?? My doctor doesn’t seem to think it is related, however he hasn’t seen me, I have just talked to his nurse on the phone.

    My second question is, is a 1mm and 4mm herniation enough to warrant surgery?

    Lastly, because this is a worker’s compensation case I have not yet seen a spine specialist, just a Physiatrist. Is this also the normal situation? I am worried about permanent nerve damage because I now walk with a limp. I am only 31yrs old and this concerns me.

    Thank you for your time

    Donald Corenman, MD, DC
    Moderator
    Post count: 8436

    You had a back injury about 5 months ago at work that apparently has not improved at this point. Your pain is lower back and well as left buttocks down the leg. You have had a CT scan without a myelogram that demonstrated a 1 mm HNP at L4-5 and a 4 mm HNP at L5-S1.

    Let’s start at the beginning. What is the percentage of your pain in the lower back vs. the buttocks and leg? 60/40, 70/30, or the reverse? What makes your pain better and worse? Walking, standing, bending, sitting, lying down? You note weakness in your left leg. It is because of pain inhibition or true weakness (can’t get the muscle to fire with or without pain)?

    What side is the larger disc herniation spotted by CT scan? Did you get temporary relief from the epidurals (the first 2-3 hours) or was that time period data not recorded (pain diary- see website).

    Where is your headache after the epidural? Front of the head, eyes, back of the head, base of the neck?

    I need more information.

    Dr. Corenman

    HezWag
    Member
    Post count: 2

    Dr Corenman,

    I now have the CT interpretaion in front of me and I will type out what it says:

    At L4-L5 there is a minimal annular disk buldge measuring 1-1.5mm.
    At L5-S1 a central broad based herniation measures up to 4mm in thickness. This extends predominantly into the ventral epidural space.

    I would say the percentage of pain is approx 60-40 with the most of it being located in the back. My pain is worse by doing anything for an extended period of time. Sitting, standing, or lying down. To this point if I sit too long I need to stand and so on. When the doctor tested my strength and ability to hold my leg up against pressure I am now unable to do so. No matter how hard I try I can’t hold resistance against pressure. As well as the limp in the left leg. I did not get any relief within the first few hours after the injection. The minimal relief occured about 4-5 days after the injection and lasted approx 1 week.

    The headache is located more towards the front of the head and is throbbing in nature. It is also non-positional, so I am aware that this is probably not a spinal headache.

    Thank you for your time

    Donald Corenman, MD, DC
    Moderator
    Post count: 8436

    OK- you have mostly lower back pain and that pain is increased with any mechanical maneuvers. The CT scan does not give great information on the health of the disc. It may appear that your L5-S1 disc is more degenerative than the L4-5 disc based upon the disc bulge. This may be more advanced than you can ascertain but do any of the endplates have fractures in them?

    The weakness of lifting of the leg I will assume is when you are lying on your back and lift your leg up at the hip joint (flexion of the hip). You cannot resist the downward pressure of the doctor’s hand on your thigh. This is a result of weakness of the psoas muscle and would not be related to disc degenerative changes in the lower lumbar spine as the psoas muscle is innervated by much higher up nerve roots.

    This back injury at 5 months of age is not improving. I hope you have already gone through a core strengthening program and Pilates. If not- that is your next stop.

    The headache does not sound like dural irritation from the injection but from something else.

    Dr. Corenman

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