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  • snackcake
    Participant
    Post count: 3

    Hello Dr. Corenman,

    Your forum is an incredible source of information – thank you for all that you do to go above and beyond what others in the health profession do. I was motivated to post because I am at a crossroads where I feel like I am at the craps table and any roll will result in crap :(

    History:
    45 y/o female, 5’6″, 135lbs, non-smoker, diagnosed with minor cervical scoliosis (age unknown, but young), was not severe enough for bracing but has caused me issues in my neck/left shoulder entire life (recently was told I essentially have a constant charlie horse in my neck/shoulders). I have very little mobility in my neck due to it being completely straight (no S curve in spine). I was an athlete, played tennis through college, basketball, volleyball, running, cycling and hiking were my main sports of choice. I always had lower back tightness, aches and pains from time to time, tight hamstrings entire life, very tight muscles in hips leading to what I thought were piriformis issues, was never able to sit “indian style”…essentially inflexible.

    Fast forward to 2017…I was very active at the time and started to notice lower back tightness and stiffness when bending over but nothing debilitating. One evening I bent over and twisted to the right to spread my bed cover (who makes their bed before going to bed???), and a pain I never felt before washed over my lower back. That evening the pain progressed to a debilitating level, I had a vasovagal response to the pain (almost fainted and almost threw up upon standing up to go to the rest room that night)and knew this was different/I had injured myself. I went to a chiropractor that I trusted implicitly and she stated she would not touch my back, it was inflamed and “had a fever”. She said I may have suffered an annular tear and if it doesn’t improve, to get further diagnostics.

    In addition to the pain in the center of my back, I had radiating pain on my left all the way down to my heel (which was mostly burning). I went to my PCP, where I failed multiple nerve tests and he ordered a MRI. It showed a bulge at both the L4/L5 and L5/S1 and annular tear on the right side of the L4/L5. He ordered PT, meds and sent me on my way. It took a good 2 months for the back pain to subside, walking seemed to help, PT helped with the left radiating pain but it still felt like the piriformis pain I had my whole life was at a new level, and since this initial episode, has never gone away.

    Since then, I have stopped playing tennis or doing any strenuous activity, heavy lifting or bending twisting. I stretch, do core work, apply heat when not in acute pain, ice when in acute pain and see a massage therapist. Prior to that, I tried acupuncture and chiropractic care but it didn’t help. I cannot sleep on my left side, there is a constant ache, burn in my upper glute/hip area, I still get piriformis type pain regularly, feel weaker on my left side when walking or hiking. About 2 times per year I suffer acute pain after inadvertently triggering the injury. This past April was by far the worst episode. The pain is an 8 of 10 when it happens, NSAIDs do nothing, the only position I can tolerate is lying down on my back with a pillow under my knees, sneezing or coughing are terrifying, climbing stairs is excruciating, cannot get up or out of bed without help, cannot dress myself or put a towel on my head after a shower…you get the drill. If you touch my foot, the pain in my center lower back is like a lightning bolt. Strangely, the left sided pain seems to go away during these episodes but it could be masked by the debilitating pain and it returns after the crisis stops (typically takes 4 weeks to get out of acute pain).

    I decided enough was enough and went to see a specialist (was a neurosurgeon) to craft a plan since my condition has only gotten progressively worse. After examining my 2017 MRI and doing some testing, he determined it was likely mechanical in nature and even pointed out what looked to be a deformity in the L5/S1 that wasn’t noted on my MRI report but needed a CT SPECT to confirm. CT SPECT report said nothing but when he viewed the images, it was clear as day that I had a unilateral left sided fracture in two places and spina bifida occulta. He said I had a bone essentially floating in my spine as it was a complete fracture on both sides. He gave me a Medrol pack, which helped, and said to avoid surgery as long as Medrol helped with the episodic pain. He even went on to say that if I saw a ortho spin surgeon, they would all likely recommend surgery and he is not convinced surgery would solve my issue. This still wasn’t a plan though so I saw a 2nd doctor (ortho spine surgeon) and they took Xrays, which showed the fracture clear as day, he spoke very fast but said I had instability, mentioned the word isthmic but never said a word about any slippage and said surgery was the only fix to my situation. He ordered a new MRI to see how the disc damage has progressed and to confirm his initial thought process.

    MRI was taken a week ago and did show progression (bulges went to herniations):

    L1 – 4 are all normal height

    L4/L5 small left paracentral herniation. No central canal stenosis with the thecal sac dimension 13mm.
    L5/S1 small right paracentral herniation, with slight thecal sac indentation, canal 11mm. Posterior laterally on the left there is a dysmorphic left lamina probably developmental, with hypoplasia and convexity outward deformity of the posterior elements on the left. The midline 6 is shifted to the left as well.

    Impression:
    1. Dysplastic left side laminotomy at L5. This would be best assessed by CT if needed for clinical or presurgical assessment
    2. Small herniations L4/L5 and L5/S1 without significant canal or foramen narrowing.

    I have yet to have my follow up with my doctor as he canceled my appointment last minute but impression 1 has me concerned. Am I destined for surgery? Minus the 2 severe episodes per year that last 4-6 weeks since 2017, my left sided pain is tolerable but still limiting/annoying. I am terrified of surgery and concerned it only leads to future surgery/pain. I am young and have dreams of hiking Patagonia, flying to New Zealand…if I have surgery now and I end up not being able to do those things, being devastated would be an understatement. But I also realize that no amount of PT is going to repair this deformity and to stop the progression of impact on my discs, I likely need it at some point.

    Any advice would be greatly appreciate, and I apologize for the lengthy post.

    Kristi

    Donald Corenman, MD, DC
    Moderator
    Post count: 8465

    You note: “the pain progressed to a debilitating level…I had radiating pain on my left all the way down to my heel….ordered a MRI. It showed a bulge at both the L4/L5 and L5/S1 and annular tear on the right side of the L4/L5…., I still get piriformis type pain regularly, feel weaker on my left side when walking or hiking. About 2 times per year I suffer acute pain after inadvertently triggering the injury…typically takes 4 weeks to get out of acute pain”

    CT Spect scan noted “I had a unilateral left sided fracture in two places and spina bifida occulta”

    MRI was taken a week ago noted:
    1. Dysplastic left side laminotomy at L5. This would be best assessed by CT if needed for clinical or presurgical assessment
    2. Small herniations L4/L5 and L5/S1 without significant canal or foramen narrowing.

    It sound like the bottom line is you have a pars defect on the left at L5-S1 with an SBO (spina bifida occulta). The pars defect with the SBO means you have a floating left facet (it is not attached or functioning). Generally, this makes the L5-S1 level somewhat unstable and probably your spine translates (rotates) and “bangs” into the left L5 root, causing nerve root pain as well as low back pain. When this level translates, your probably also cause an annular tear and you get what I call a “low back attack” where you are useless for a period of time.

    Your first need a diagnostic/therapeutic nerve root block at left L5-S1. You would need to keep a pain diary to prove that this is the level of pain generation. See https://neckandback.com/treatments/epidural-injections-and-selective-nerve-root-blocks-diagnostic-and-therapeutic/ and https://neckandback.com/treatments/pain-diary-instructions-for-spinal-injections/ and “https://neckandback.com/treatments/diagnostic-vs-therapeutic-injections/. This injection can last a considerable amount of time and can be used as a treatment tool. If however, it does give you short term pain relief but not long term relief, you probably have to consider surgery.

    You note: “I am terrified of surgery and concerned it only leads to future surgery/pain”. This is not true for at least 90% of patients with your disorder that undergo a fusion of L5-S1. Once fused, you should be able to regain your prior athletic self and within reason, reengage those activities.

    Dr. Corenman

    snackcake
    Participant
    Post count: 3

    Thank you so much Dr. Corenman – you articulated the bottom line very well. I have a consult with another doctor next week since the first ortho spine surgeon out the gate said my only recourse was surgery and I will ask for the nerve root block as a next course of treatment. This has given me hope.

    I forgot to put the findings summary from the recent MRI, which appears to note no slippage (assuming no subluxation means slippage):

    Normal lordosis and verebral height. There is absence of normal pars interarticularis and lamina on the left at L5 and sagittal views. No definite pars defect or abnormality posterior elements in the right. No subluxation. No suspicious marrow signal.

    When I look at the CT SPECT images, the left pars looks like someone took a hammer to it and crushed it so no doubt it is floating around, hitting nerves and when it does, holy moly…

    Donald Corenman, MD, DC
    Moderator
    Post count: 8465

    Dysplasia is what probably has occurred to the left pars. This means continuous breaking of the pars as it tries to heal, fragmenting it. If there is no slip and the disc looks normal, you can consider a pars repair with an SBO repair at the same time but if it is atrophic (thinned out) or there is any degeneration of the disc, a fusion should be considered instead if surgery is contemplated.

    Dr. Corenman

    snackcake
    Participant
    Post count: 3

    Thank you so much – the MRI did indicate dysplasia of the left pars and the CT does look like multiple fractures to me, the untrained eye :)

    I am in CO typically one month per year so if the nerve block doesn’t do the trick, I will schedule a consult in the event all else fails and surgery is in scope. So impressed with your knowledge and support, and I think that is paramount when considering surgery/choosing a surgeon.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8465

    Please keep us apprised of your plans.

    Dr. Corenman

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