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  • rbryant
    Participant
    Post count: 5

    Good afternoon, Dr Corenman,

    I have had recent issues with my lumbar spine. My symptoms have included: morning back most prominent on right side of spine, pain in anterior thigh, and now pain and numbness in top of foot and third/fourth toes. Of note, I have a small nodule to the right of my spine. When palpated, I can occasionally mimic the same pain pattern. I have not had pain in the back of my leg or bottom of feet.

    I have been in PT for months with minimal benefit. I had an ESI on 6/4 with no results, this was in L5/S1. My pain mgmt. provider would like to try an ESI on L4/5 next.

    I had an MRI around 6/1 and the following is the report:

    L1-2: No significant canal stenosis or neural foraminal narrowing is identified.
    L2-3 No significant canal stenosis or neural foraminal narrowing is identified.
    L3-4: No significant canal stenosis or neural foraminal narrowing is identified.
    L4-5: There is a disc bulge. There is facet arthropathy. There is a small central disc protrusion. There is mild bilateral neuroforaminal narrowing.
    L5-S1: There is a disc bulge. There is facet arthropathy. There is a right paracentral annular tear. There is moderate and mild left neuroforaminal narrowing.

    Impression: Degenerative disc disease and spondylosis with multilevel neuroforaminal narrowing as above.
    Small central disc profusion at L4-5.

    Would I be a candidate for a discectomy, or even lumbar fusion at L4-S1? And, is it possible that the nodule to the right of my spine is causing cluneal nerve entrapment or compression?

    Thank you very much…

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    The question that has to be considered is if you have instability and/or a degenerative spondylolisthesis at L4-5. This would fit with many of your symptoms and findings on MRI (“L4-5: There is a disc bulge. There is facet arthropathy. There is a small central disc protrusion. There is mild bilateral neuroforaminal narrowing. L5-S1: There is a disc bulge. There is facet arthropathy. There is a right paracentral annular tear. There is moderate and mild left neuroforaminal narrowing”.

    I do think a diagnostic epidural steroid injection at L4-5 is a good consideration. See https://neckandback.com/treatments/diagnostic-vs-therapeutic-injections/and https://neckandback.com/treatments/pain-diary-instructions-for-spinal-injections/.

    Flexion/extension standing X-rays are important to look for instability or slip.

    It is highly unlikely that you have cluneal nerve entrapment.

    Dr. Corenman

    rbryant
    Participant
    Post count: 5

    Dr Corenman,

    Thank you for your time and response.

    In the event of instability at L4/5, what is typically the appropriate treatment, provided that conservative treatments such as PT and injections have failed.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    If it’s true instability but the instability is mild, sometimes a simple decompression will do but many times, a fusion of the segment is required.

    Dr. Corenman

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