[Donald Corenman, MD, DC]

#6889

“Cracking sounds” are typically associated with movable bony surfaces but don’t immediately think that there is a pseudoarthrosis (non-fusion) at the L3-S1 level. This sound can originate from L2-3 or the sacroiliac joint. If you feel a shifting in the fusion area however and you are sure this is not originating from the levels above or below the fusion, this could indicate a pseudoarthrosis.

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.

[SpinelessWench]

#6890

Alrighty, thanks for your reply this morning..

And continued success in your practice.

S.W., NC

[Donald Corenman, MD, DC]

#6892

Thank you.

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.

[SpinelessWench]

#6911

Dr. Corenman,

I was fairly confident that I’d posted my last question to you, however there’s been a recent development in my situation and I wanted your input. Given the less-than-informative visit to the 2nd opinion orthopedist, whose glance at my MRI revealed “absolutely no stenosis”, I decided the other day to contact the neurosurgeon who has performed four of the nine surgeries I’ve had on both my lumbar and cervical spine. This surgeon has known me for 24 years, and is more than familiar with my spine. We have always had an incredible doctor / patient rapport, and I respect him immensely. He’s also an excellent diagnostic “detective”, and will consider every neurological etiology imaginable as a potential instigator for a patient’s symptoms. We spoke by phone a few days ago, and I summarized not only my current lower lumbar / extremity pain, but the wide variation in possible diagnoses and interpretations of my MRI images.

He immediately offered a possibility as to the cause of my symptoms, and also told me that many orthopedists and neurosurgeons alike oftentimes fail to consider it (most often inadvertently, or simply because it’s off their diagnostic radar). He then told me that my symptoms were classic for stenosis, yet the problem may lie in the sacral plexus region. My MRI did not include the sacral ala, the iliac joint, or anterior views of the joints below S1, so prior surgeons were unable to even consider this component of my spine. He then mentioned that recent neuro-orthopedic research is now beginning to focus on the sacrum as an overlooked culprit of severe lumbar pain, lower extremity pain, and radiculopathy. “When surgeons hear these symptoms”, he said, “many automatically start looking at the disks and foraminal outlets at and above L-5, so they can actually miss the problem because it’s just out of view on the images or X-rays.” He then instructed me to send the MRI, along with a very concise list of my symptoms… I was obviously grateful that he offered to do this.

MY QUESTION FOR YOU:

My low lumbar pain is severe (> 8 all the time) and is bilaterally diffuse across what I can only estimate to be about 2 inches above the top of the “butt crack” (I’m sure there’s a medical term for butt crack, but I didn’t bother to Google it first)… This pain then radiates bilaterally down both legs, but is NOT in the posterior thigh. The pain originates in the sacral band across my low back, then migrates around to the anterior upper thigh/groin. It then travels down the anterolateral thigh, to the lateral knee, then down the lateral leg to about mid-calf, also lateral. Occasionally, it migrates to the lateral ankles and into my feet. The only parasthesias I notice are tingling in the soles of the feet. I also have severe neurogenic claudication. Relief is attained by flexion. I have no bladder or bowel issues, nor is there saddle anesthesia. I also experience sudden, and extremely painful “taser gun” sensations in both hips at the top of the buttocks, which occur suddenly while standing or walking.

Do these symptoms correlate with sacral plexus nerve outlets, and is it possible that a patient can develop degenerative issues in this sub-lumbar area? What are the symptoms associated with SI involvement or the sacral extraforaminal ventricles? And, if there is nerve compression in these sacral outlets, what is the typical surgical technique?

I really appreciate your help. I have a suspicion that my long-time neurosurgeon may be on to something.

S.W., NC

[Donald Corenman, MD, DC]

#6915

There is a debate regarding the sacroiliac joint as a pain generator in spine surgery circles. I do believe this joint can cause pain but not to the extent that many others do. You do have a situation that the sacroiliac joint has more stress than normal (three level fusion to the sacrum) but your symptoms do not reflect sacroiliac pain.

Sacroiliac joint pain is local pain right over the joint itself that can radiate to the buttocks and rarely the posterior thigh. This is not your pain. The sacroiliac joint is incapable of generating “stenotic” type pain as there are no movable foramen or nerve exit holes that can change in diameter with motion.

“Butt crack” is a term we spine surgeons should use as it is perfectly descriptive but unfortunately we have to use “gluteal cleft” instead.

Pain that originates in the sacral region, radiates into the anterior thighs and down to the lateral mid-calf is in the referral area of the L2 through the L4 nerves. If you have a fusion from the sacrum to L3, there are two possibilities for pain referral. One is a pseudoarthrosis at L3-4 that is causing nerve compression. The other possibility is a breakdown of L2-3 with nerve compression from this level.

Your symptoms are classic for mechanical compression due to spine position which is very common. The MRI may not demonstrate significant compression but the standing flexion/extension x-rays may reveal this instability. Selective nerve root blocks should yield temporary relief (see SNRB and pain diary on the website for further information).

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.

[SpinelessWench]

#6919

Dr. Corenman,

Your review and reply this morning is really appreciated; it’s unfortunate that patients like myself, whose pain and other symptoms are obviously originating from somewhere, are forced to investigate and research their conditions themselves. In a matter of six weeks, I’ve had two surgeons all but shrug off my symptoms, sending me out the door with vague or otherwise nebulous “diagnoses” simply because they lack the initiative to investigate just a little bit deeper in order to find the etiology of the pain. Because I’ve undergone 9 spine surgeries, and have an extensive amount of post-operative scarring and arthritis, I’m now presumed to be beyond the short amount of time it would take a curious or inquisitive surgeon to investigate additional possibilities for my symptoms. I fully understand that there comes a time when operative or invasive procedures would be futile or otherwise detrimental to the patient… I’m a realist, and completely comprehend the notion that surgery isn’t always a “cure all” for patients with complicated and extensive spinal histories. But, my symptoms are very specific, and both my pain management team (two excellent anesthesiologists) and my long-time neurosurgeon are in agreement that my symptoms are “classic presentations” of stenosis and/or instability at very localized levels in my lumbo-sacral spine.

Exactly as you suggested, my MRI yielded “nothing” in the opinion of “2nd opinion guy”, and severe stenosis in the opinions of two radiologists and my PM team. Since there is titanium artifact from L3 to S1, an absolute determination has yet to be established. It seems likely, however, that L2/3 is the suspect — my symptoms are a textbook presentation of compression at that level, and the sagittal views clearly show disk bulging there. The radiologist noted “diffuse disk bulge”, with “moderate to severe foraminal stenosis bilaterally.” And again, 2nd opinion guy all but insinuated that the radiologist was hallucinating and possibly possessed by little green men… It’s all maddening, but at the same time, comical.

As the patient, the one who’s living with acute pain and diminished quality of life, I think a logical gameplan is needed BEFORE I have the Medtronics neurostimulator implanted. On Monday, I plan to talk with my PM physician to request a few more plain X-rays of my lumbar spine that include views of the sacral and SI structures. As you recommended, I plan to request flexion and extension views. If pseudoarthrosis or spondylolithesis are present, those views would clearly identify them. I’m not sure if this is relevant, but one of the reasons my fusion extended to S-1 years ago was due to spondylolithesis at L5/S1. The orthopedic surgeon who performed that surgery (2008) tactfully warned me that I’d likely have problems at L2/3 in the future, given the increased load that level would have to endure.

Before I have a $30,000 device implanted, I think I’m being prudent in covering all the bases to determine what, exactly, is causing this. My PM physician would likely agree that perhaps a CT scan with contrast might help illuminate compression obscured by artifact in my MRI. Or, would a myelography be helpful in this situation? Finally, if L2/3 is found to be the origin of my symptoms, would a fusion extension to T11 or so be warranted, or could that level be repaired without fusing upward? Aside from flexion and extension plain films, can you lend an opinion as to whether any of the diagnostic procedures I’ve mentioned would help narrow this problem down?

I’m sure that during your career, you’ve encountered patients just like me — extensive spine issues, and a long history of surgeries — who just want an answer or somewhat definitive diagnosis. Whether surgery could help is almost secondary… In other words, just knowing WHAT it is, whether it can be fixed or not, makes it a little easier to live with and tolerate.

I look forward to hearing from you when you have time… Thanks again.

S.W., NC

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