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  • dk_atx
    Member
    Post count: 2

    Dr. Corenman — thank you for providing this valuable service.

    I’m an otherwise healthy 35 year old male who has been suffering on and off (mostly on) for the past 4+ months and the frustration and worry is really starting to get to me. I’ve decided to write up an extensive history of my pain using your guide as a template (I figure this will be useful for visits to specialists in the future).

    My primary question right now, if you are able to address it, is: what is the likelihood that conservative treatment is going to result in full recovery? It seems like the annular tear in my L5-S1 is the source of my problems, and I have heard a wide range of belief on whether or not this is likely to heal on its own, and in what time period. Am thinking about visiting a spine surgeon in the near future for additional opinions, but would appreciate your perspective on my case.

    Here’s my report:

    LOCATION AND QUALITY OF PAIN

    Primarily a constant, dull, tight, aching pain or soreness in the lower back, with periodic pain (dull, aching) in groin, buttocks, and both legs (have felt symptom further down the right leg all the way to the feet, no further than the thigh on the left leg). Sometimes leg pain appears suddenly but it’s hard to describe as “shooting.” 80%/20% pain distribution back vs legs, again the back is kind of the standard and the leg pain comes and goes.

    Activity has been mostly limited of late, so it’s hard tos ay that activity drives it much. Standing or sitting for extended periods of time exacerbates the pain. Of late, I’d say that the sensation is almost that of fatigue — I am generally at a level of pain that, by itself, is not debilitating, but if I sit in a chair for an hour without moving, I start to feel a “pressure” and onset of fatigue. Lying down (typically with pillows under my knees) is generally my most functional position.

    No skin sensitivity or change in tone. No ‘foot drop’ or loss of strength in legs. Can still walk short distances, perform most physical therapy exercises on most days, operate exercise bike, etc.

    INTENSITY OF PAIN

    At its worst, pain was around 7 on the VAS scale, for a period of about 10 days.

    For the past 2 weeks, I’ve been holding relatively steady at a pain intensity of 3-5. Often the pain is worse in the late afternoon / evening, particularly if I’ve had an “active” day. (My level of activity is depressingly minimal, a ‘busy’ day might involve 30 minutes of stretching, sitting at my desk for a couple of hours, and running an errand or two in my car).

    WEAKNESS

    I don’t particularly feel weak performing individual activities, but I do feel a kind of general weakness at times, again, a feeling of fatigue, like standing or sitting puts an undue amount of ‘weight’ on my body and I feel tired much of the time. Generally am able to perform most activities, just not nearly as much as I would like.

    ONSET AND LENGTH OF TIME SYMPTOMS HAVE BEEN PRESENT
    ALSO: HISTORY OF CONSULTATIONS AND TREATMENT

    12/30/2012 – pain started morning after flight home. After about a week of rest, pain went away completely and resumed active lifestyle for about 4 weeks.

    2/3/2013 – pain returned after a day of high activity (moving furniture, dancing) but in low level form. a few days later, attempted to bike to a coffee shop and arrived in excruciating pain, unable to work, ended up needing to get a ride home from a friend.

    started visits to a chiropractor for adjustment + rehab that week. improvement noticeable in the first week, then a sudden setback to high level pain (7/10). weeks of chiropractor visits had things moving in the right direction.

    mid march, pain seemed mostly gone and i attempted to start biking again. had a moderate setback, stopped biking, haven’t been on a non-stationary bicycle since. went to san francisco for a conference in late march, was mostly pain free.

    3/31 – flew back home, slept in my bed one night, and on April 1, pain returned. pain increased for the next 10 days culminating in worst pain of the experience (7+/10, completely incapable of working)

    4/12 – decided to stop seeing my chiropractor (no more adjustments) but continue with the physical therapy. went to see my GP for the first time, he prescribed oral steroids (methylprednisolone). no effect one week later, GP referred me to a pain specialist.

    4/19 – visited pain doctor, he ordered an MRI (full results below) and prescribed hydrocodone for pain management.

    short verison of MRI results to my understanding: degenerative L5/S1, disc dessication with 25% loss of dorsal disc height, annular tear, grade 1 (5%) degenerative spondyliosthesis. pain specialist recommended an epidural steroid injection.

    4/30 – ESI administered.

    5/8 – 8 days later, no real improvement in symptom. frustrated.

    ACTIVITIES

    Prolonged sitting or standing increase pain. Sitting in aeron chair is generally more amenable for longer periods of time (interrupted periodically for ‘stand and reach’ stretches). I attempt to work at a standing desk periodically but have trouble doing so for more than 15 minutes or so.

    Walking is usually pretty OK, and I can manage 15-30 minute walks with no-little extra pain. I’m not sure I would venture out for a longer than 30 minute walk at the moment.

    Had a couple of setbacks after riding a bike in the city (which was a 5-10 hour/week activity previously) so I’ve stopped. I just installed a bike trainer in my house and am experimenting with biking in a controlled situation to get cardio exercise.

    I tend to spend 8+ hours a day prone (in addition to 8 hours of sleep). I work from a prone position and can better concentrate and feel less distracted by the pain. I try to work sitting (2-3 hours a day) or standing (< 1 hour a day) which is mostly in front of a computer. Also had a couple of primary setbacks (including the initial symptom) the morning after a flight. PAIN INTERVALS Pain is pretty constant and doesn’t seem particularly exacerbated by any one motion or movement, rather it accumulates with daily stress. As described in my history, I’ve had periods of pain lasting between 1-4 weeks. The current episode is in its 6th week with no sign of abatement. ACTIVITY AND OCCUPATIONAL RESTRICTIONS The pain has been strongly disturbing my life along many key axes. I am incapable of focusing on work for more than 20-30 hours a week in a good week. Work meetings are frequently interrupted as I have to move or lie down to alleviate the pain. Social life is restricted, I can’t go out as much or be nearly as active with friends. I’ve had to abandon scheduled vacations, such as a recent planned camping trip. Dating seems like an impossibility right now. I do attempt to go out a few times a week but generally have to cut my activity short. Bicycling was my primary exercise and has been abandoned for the past 2 months, though I am attempting to reintegrate it as an exercise in a controlled environment (with a bicycle trainer). I do 15-60 minutes of physical therapy, core strength exercises, and so forth, on a daily basis, including working with a physical therapist for 2 hours a week. I run my own business (video game development) which is a blessing and a curse — I don’t have to take time off when I’m incapable of working, but I also have no disability options, and my business suffers if I am incapable of working. My work duties mostly involve operating a computer. I’ve missed a lot of hours this year as a result of this issue. MRI RESULTS (4/19/2013) Technique: High field strength multiplanar imaging of the lumbar spine without gadolinium. Findings: L5-S1 grade 1 degenerative spondyliosthesis. No fracture. No aggressive nor destructive marrow pathology. The conus terminates normally L1 with no abnormal signal of the lower thoracic spinal cord nor conus. No paraspinous soft tissue abnormality. L5-S1: Disc dessiccation with 25% loss of dorsal disc height. Increased T2 signal in the dorsal annulus, less than CSF intensity, age indeterminate likely old annluar tear. Disc protrusion associated with annular tear 2 by 11 mm AP by transverse diameter. Mild to moderate deformity of ventral thecal sac in conjunction with spondyliosthesis, approximate 5% degenerative spondyliosthesis. No mass effect on descending nerves. Mild left more than right facet arthorpathy with ligamentum flavum buckling on the left, 3-4mm. Mild to moderate left and mild right neural exit foraminal compromise, potential for irritation of exiting left more than likely right L5 nerve with weightbearing, more so there is instability. L5-L4/L4-L3/L3-L2/L2-L1 – Normal disc hydration, normal disc height, no disc hernia, no mass effect on descrending nerve roots, fat preserved around exiting nerve roots, no facet arthropathy detected.
    Much obliged for your time and attention,
    David

    Donald Corenman, MD, DC
    Moderator
    Post count: 8468

    You have performed an excellent job in recording your history. This really gives me most of the information needed to lend some advice.

    Your problem is more than just an annular tear. You have a degenerative spondylolisthesis of L5-S1 which means this is a global breakdown of the stabilizing structures at this level. The facets are the bony structures that prevent forward slip of one vertebra on the other. These facets have to fail in order to allow the vertebra to slip forward (as is the case with a degenerative spondylolisthesis). With the failure of the facets, the disc is subjected to sheer forces that eventually produce the annular tear (discs do not tolerate sheer forces well).

    This global failure then allows one vertebra to slip on the other. Three symptoms can occur. Lower back pain is one typical symptom where any loading of the spine puts undue pressure on this segment and causes stretch of structures that are imbued with pain nerves (nociceptors).

    The second symptom is instability. This is the apprehensive feeling that if you put your back in a certain position, the back will “give way”. An unexpected force on the back (unexpectedly stepping off a curb that is deeper than expected) will cause a severe pain in the back that will almost drop you to your knees.

    The third symptom is nerve pain that radiates down the legs with standing and disappears with sitting, leaning forward or lying down. This occurs due to the compression of nerve roots with extension (bending backwards-necessary for standing and walking).

    Just to be sure, the most common slip at the L5-S1 level is an isthmic spondylolisthesis (see website) so make sure this condition is ruled out and the problem really is a degenerative spondylolisthesis. The treatments do differ.

    The best treatments for this disorder are a core strengthening program with neutral spine precautions and epidural steroid injections to calm down the nociceptors. If you fail all conservative treatments, this disorder responds very well to surgery.

    Dr. Corenman

    dk_atx
    Member
    Post count: 2

    Thanks Doc!

    My pain specialist seemed to think that the spondylolisthesis was minor at 5%, and that it was more likely that the pain was related to the fissure in the disc. This definitely gives me something to think about asking before my next visit.

    Some quick follow-up questions.

    1. Regarding isthmic vs degenerative spondylolisthesis, is this something that should be apparent in an MRI image? Just wondering how I can accurately verify what I’ve got.

    2. I had an ESI a week and a half ago and I don’t really feel like it made a difference — had a couple of better days but mostly feel like I’ve been in the same place pain-wise since before the shot. Do you feel like the upside is high enough that it’s worth getting a follow-up injection?

    3. My pain specialist had discussed using a discogram to accurately diagnose the source of the pain. I’ve discovered that there’s some amount of controversy over the use of discograms (due to their invasiveness, it sounds like) — do you typically recommend this as a diagnostic procedure, or is it better to wait until I’m seriously considering surgical options?

    4. Any thoughts on PRP injections for a degenerative disc? Also an option mentioned by my pain doctor, research is kind of spotty on the topic.

    Thanks!

    Donald Corenman, MD, DC
    Moderator
    Post count: 8468

    Pain can be generated by the disc, facet or nerve. The slip at “only” 5% is still a slip with the fact that global failure of this segment (disc and facets) has to occur. This is much different than an annular tear by itself.

    In any slip (or any patient with pain for that matter), standing X-rays with flexion/extension views needs to be included. These are the only tests that dynamically can determine what the mechanical status of the segments are.

    The MRI can demonstrate the pars fractures associated with an isthmic spondylolysthesis but the images have to be high quality and the radiologist has to look for these fractures as they are subtle to identify. The X-ray sometimes is a better tool to identify these fractures.

    Normally, if an epidural was ineffective, i will not order a second. There are rare times a second can be effective but that percentage is not high.

    I am a fan of discograms in the correct settings. I use the discogram as a preoperative test however. If you are not contemplating surgery, I would not have a discogram.

    PRP in my opinion is not generally effective for disc pain or instability and has no place in the spinal canal.

    Dr. Corenman

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