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  • epqe17
    Member
    Post count: 4

    Dr. Corenman,

    I have read through your website and I am in desperate need of your help. I am a low back (L5-S1) patient that has had everything done over the past four years without any success (only local 3-4 level pain when walking that also includes a good deal instability while walking – with a pronounced 20 degree backward lean). I am now very close to deciding on Anterior or Posterior Fusion Surgery to provide more stability to L5-S1 where I have a 2-4MM retrolisthesis (can be seen on any of the MRIs).
    Before I go under the knife with a doctor I would like your opinion on what is really causing the backward lean from a kinesiological perspective. Can this be caused through a naturally fused L5/S1 vertebrate? One interesting symptom is that I can walk without pain by leaning forward, but my erector spinae eventually win out (within one minute) and I then walk with a pronounced backward lean (with pain at the L4-S1 area). At this time I have a “jerky” walking motion as I try to remain vertical but my body is pulling me backward. Every orthopedic surgeon that I have seen has called me an enigma (as every patient leans forward).

    Here is my back history(not that interesting):
    -Mid – August 2007 – Landed awkwardly when jumping from a rock formation and had acute pain for 2 days
    -Late – August 2007 – Saw Chiro- pain subsided to a 2-3 level from 8-10- Local to L5-S1 and it doesn’t travel down the legs
    -September 2007 – Had 10 sessions of rehab – no real results – still 2-3 level pain
    -September 2007 – MRI – Results indicate L5/S1 compression and dry disks (not uncommon for a 43 year old man)
    -October 2007 – Had a steroidal med pack – still 2-3 level
    -January -March 2008 – 28 DRX treatments at a chiropractor – No real improvement – still 2-3 level
    -July- January 2008 – Saw Chiropractor – Active manipulation – No real improvement – 2-3 level
    -December 2008 – Had second MRI – no differences noted from the previous MRI
    -February 2009- Saw Ortho again and he recommended pain management
    -March 2009 – Visited a pain management specialist and he suggested facet vs. epidural injections
    -March – June 2009 – Saw Chiro – cold laser therapy, active manipulation – No Real improvement – 2-3 level when walking
    -January 2010 – Facet Joint Injections to L5-S1 (4 joints) with no reduction in pain and, in fact, an increase in anterior pelvic tilt and pain/instability when walking – pronounced backward lean when walking!!!!
    -December 2010 – Facet Joint Injections to L5-S1 (4 joints) with no reduction in pain and, in fact, an increase in anterior pelvic tilt and pain/instability when walking – more pronounced backward lean while walking!!!!
    -Current – Given up believing that chiropractic techniques will resolve pain for me and have seen many spine surgeons about my case – they indicated there may be a natural fusion in 3-4 years, however, I can’t really live with my current walking condition(unstable with pronounced backward lean)! What if if fused with the lean permanently?

    Enclosed is my latest MRI report (and images) and my latest CT Scan report (and images) that outline the slight retrolisthesis and slight L5 herniation abutting the thecal sac at L5-S1. Basically, my L5-S1 disk no longer exists and osteophytes have started to grow(see ct spinal cross section.jpg). With my instability while walking creating a severe backward lean (I can walk backward fine) I am running out of nonsurgical options.

    I would appreciate a response if you believe something can be done from a kinesiological point of view. I can no longer walk forward without a backward lean of 20-30% (however I can walk backward without issue). This happens in a “jerky” fashion as I try to straighten to vertical, but I’m pulled backward constantly as i walk. I would appreciate your opinion before setting up an appointment.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8459

    There are a number of unanswered questions regarding your biomechanics. A “backwards lean” (extension posturing) could be from any number of conditions. What does your standing lateral X-ray show? What is your lordotic angle measure? What does your sacral angle measure? What is your pelvic tilt angle?

    What do your flexion/extension X-rays demonstrate? What is your global range of motion of the lumbar spine?

    Do you have a lateral scoliogram X-ray? What is your positive or negative sagittal balance? Do you have a thoracic hyperlordosis (Scheueremann’s disorder)?

    Backwards leaning can also be antalgic (holding a posture to reduce pain).

    As you can see, the biomechanics of your condition is still relatively unknown according to your current understanding. You need more workup to determine what is causing the pain and the lean.

    Dr. Corenman

    epqe17
    Member
    Post count: 4

    My images can be found at https://docs.google.com/present
    To answer your specific questions:

    1. My standing lateral X-ray indicates decreased disk height at L5-S1 and significant osteophye growth. T11-T12 and T12-L1 have Schmorl’s nodes and reduced disk height.

    2. The specific angles have not been calculated, but you should know that the pain actually occurs after the extension posturing occurs (not before). My body isn’t reaching the extension posturing due to pain, but it is created after extension. As I try to straighten, my body is forced back to extension and more pain.

    3. Flexion/extension xrays are included in the link.

    4. I do not have a scoliogram X-Ray, but I do not have any signficiant scoliosis.

    What I do want to provide you is the actual MRI report and CT Scan report text:

    MRI:

    FINDINGS:
    There is no abnormal signal evident to suggest fracture. The pars interarticular are intact.

    T12/L1:Small anterior disc bulge is evident with disc space narrowing and disc desiccation. There is no central canal stenosis or neuroforaminal narrowing.

    L1/2: There is no disc bulge or protrusion. There is no central canal stenosis or neuroforaminal narrowing. The facet joints are preserved.

    L2/3: There is no disc bulge or protrusion. There is no central canal stenosis or neuroforaminal narrowing. The facet joints are preserved.

    L3/4:Disc desiccation is evident with high signal in the 6 o’clock position of the annulus reflecting an annular tear. Small superimposed disc protrusion with minimal inferior extrusion is evident that deforms the ventral thecal sac without central canal stenosis. There is no neuroforaminal narrowing. Minimal left facet arthropathy is evident.

    L4/5: Disc desiccation is evident with diffuse disc bulge symmetric to the left extending into the left neuroforamen. The disc bulge causes flattening of the thecal sac without central canal stenosis. Mild bilateral facet arthropathy is evident. All this causes bilateral neuroforaminal narrowing, mild on the left and minimal on the right.

    LS/S1:Diffuse disc bulge is evident asymmetric to the left extending into the left neuroforamen. Small superimposed central disc protrusion is evident. Bilateral facet arthropathy is identified. Prominent disc space narrowing with endplate Modic change is noted. Endplate osteophytes are appreciated. The disc bulge, endplate osteophytes and facet arthropathy cause bilateral neuroforaminal narrowing, moderate to severe on the left and moderate on the right. The disc bulge and endplate osteophytes contact the exiting/exited nerve roots.

    The paraspinal soft tissues are grossly unremarkable.

    IMPRESSION:

    1. T12/L1: Small anterior disc bulge

    2. T12/L1, L1/2, L2/3 and L3/4: No central canal stenosis. No neuroforamlnal narrowing.

    3. L3/4; Disc protrusion. Minimal Inferior disc extrusion. Annular tear.

    4. L4/5; Disc bulge asymmetric to left Into left neuroforamen. No central canal stenosis. Bilateral neuroforaminal narrowing, mild on the left and minimal on the right.

    5. L5/S1: Diffuse disc bulge asymmetric to left into left neuroforamen. Central disc protrusion. Bilateral neuroforaminal narrowing, moderate to severe on the left and moderate on the right. Contact exiting/exited bilateral L5 nerve roots.

    CT SCAN:

    -There is minimal retrolistliesis of L5 on Sl.
    -The vertebral bodies are normal in height.
    -Schmorl’s nodes are seen at Tll and Tl2 levels.
    -There is reduction in disc space at T11-TI2, Tl2-L1 and L5-S1 levels.
    -There is contiguous endplate irregularity with vacuum phenomenon in the disk at L5-S1 level.
    -T11-T12, T12-L1, L1-L2,and L2-L3 levels: Mild bilateral facet hypertrophy is seen. There is also mild bilateral neural foraminal narrowing at T11-T12 level.
    -L3-L4 level: There is a disc bulge with a bilateral facet hypertrophy and mild canal stenosis.
    -L4-L5 level: There is a disc bulge with a bilateral facet hypertrophy causing mild canal stenosis and mild narrowing of bilateral central foramen.
    -Pre and paravertebral soft tissue is normal.
    -Spina bifida is seen at S1 level.
    -There is evidence of sclerotic lesion likely a bony island.
    IMPRESSION:
    -Multilevel degenerative changes seen in the lower thoracic and lumbar spine, as described above.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8459

    Sorry but I had to delete your images as this is an anonymous forum and identifying features cannot be used.

    You have typical isolated disc resorption at L5-S1. This is characterized by complete loss of the entire disc, endplate overload and endplate fractures. This is a “bone on bone” disc space. You also do have mild degenerative changes of L3-4 and L4-5 but these are most likely asymptomatic or minimally symptomatic.

    The “bending backwards” phenomenon could be from antalgia as I don’t identify (in this very limited series) any sagittal plane deformity (unusual postures from pelvis or upper spine deformity) but this is an incomplete series.

    Antalgia is posturing to avoid pain. This disc space should be painful with standing upright and bending forward as well as lifting. Pain should be somewhat reduced with bending backwards (this position loads the facets and unloads the disc). This disorder is also known for delayed onset pain (pain onset some hours later after a loading or impact activity). Vibration typically will also cause pain (prolonged sitting in a car, airplane or even on a mountain bike).

    Dr. Corenman

    epqe17
    Member
    Post count: 4

    Dr. Corenman,

    What you have said makes a great deal of sense, however, my body is reacting completely the opposite way. As I lean forward to attempt to walk more vertically there is no pain, however, I am forced (it feels as if my paraspinal muscles are firing to force me backward) backward to this 20 degree off normal position (there is no lean left or right – just straight backward). After my body has been forced to this position I feel pain as I walk. I can lean forward to alleviate the pain, but my body forces me back to the painful position.

    I have one additional image (Image 1) that can be seen in my previous link that I just added (I hope you can look at it).

    This shows a “mass” in the anterior space of what remains of the disc (within the broken end plate area) and my working theory is that the L5-S1 disc remnants have created a more solid diametrical mass and I can no longer overcome this “obstruction” to stand up straight. As I stated earlier I can bend over and touch my toes without pain so the working antalgic theory doesn’t make sense (there is no pain bending forward).

    Have you ever seen anything like this before?

    Thanks for your time as you have offered more to me in this brief summary than all 7 previous orthopedic surgeons combined.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8459

    The lean just due to the biomechanics does not make sense to me. There is something missing. The pelvis can accommodate a significant lean (increased lumbar lordosis) by anterior rotation. My understanding is that there is no pain in leaning forward but this position requires significant energy expenditure and when you “relax”, you are pulled backwards. This position is painful.

    Even if the L5-S1 disc space is fixed in extension, this by itself would not cause the backwards bend as the pelvis and discs above could accommodate.

    You might have some muscle contractures that cause this positioning. You need a thorough physical examination to determine the cause of this disorder.

    Dr. Corenman

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