[Meri]

#28762

I am a 45 y.o. Female and I pulled my back lifting a neuro patient on 10/9/17. I had an MRI on 4/2/18 for suspected L5S1 herniation after failed PT and no relief from any med (I used mostly NSAIDS, but I also have oxycodone which I use occasionally for an unrelated condition-when I used it for that condition it had absolutely no effect on my back, butt, leg, or foot pain).

The MRI came back negative other than a mild circumferential bulge at the L3L4. The workers Comp doctor stated that I was fine, it was just muscle strain and I should do “work-hardening” PT for six weeks, then return to work without restriction. I asked to return to the physiatrist/pain specialist my pcp originally referred me to as I was having worsening symptoms with continued burning in my left lower back radiating to my butt and down my leg with burning pins and needles in my foot and toes alternating with total numbness in my foot; the burning in my foot is sometimes more pronounced at night. I had a fall a few weeks ago when my foot rolled sideways. The physiatrist recommended an epidural steroid injection. I had it on 5/30/18 hoping it would be the magic that would fix this. It has gotten progressively worse since.

I’ve been referred to a neurologist for EMG. My current diagnosis is L5-S1 nerve root pain but the possibility of Piriformis Syndrome or muscular issues has been suggested, also. I’m a little concerned as, while I haven’t had incontinence or B&B issues, I’ve had an intermittent heaviness/pressure to the saddle region. Could that occur with Piriformis Syndrome? I’m also wondering if I’d benefit from an upright or positional MRI as I’ve read studies that indicate they often identify disc issues missed on supine MRI. Would appreciate any suggestion you could offer. Thank you.

[Donald Corenman, MD, DC]

#28768

Not uncommonly, a far lateral disc herniation or even foraminal stenosis is missed in the L5 foramen. I would start there. Since your foot “rolled sideways”, I would worry about a peroneal muscle weakness, common with an L5 radiculopathy. A careful examination should easily find this weakness and further enforce an L5 nerve disorder.

Normally, an EMG would not be helpful but with the lack of diagnosis in your case, it might be helpful. Piriformis syndrome is exceeding rare and most likely a red herring. Upright MRIs are generally unhelpful as flexion-extension X-rays provide plenty of information on the possibility of instability.

Read these and get a copy of the radiological report to get more information but radiologist can and do miss foraminal compression.

https://neckandback.com/conditions/missed-diagnosis-far-lateral-lumbar-disc-herniation/
https://neckandback.com/conditions/foraminal-collapse-lumbar-spine/
https://neckandback.com/treatments/emgncv-electromyograms-and-nerve-conduction-studies/

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.

[Donald Corenman, MD, DC]

#28769

Not uncommonly, a far lateral disc herniation or even foraminal stenosis is missed in the L5 foramen. I would start there. Since your foot “rolled sideways”, I would worry about a peroneal muscle weakness, common with an L5 radiculopathy. A careful examination should easily find this weakness and further enforce an L5 nerve disorder.

Normally, an EMG would not be helpful but with the lack of diagnosis in your case, it might be helpful. Piriformis syndrome is exceeding rare and most likely a red herring. Upright MRIs are generally unhelpful as flexion-extension X-rays provide plenty of information on the possibility of instability.

Read these and get a copy of the radiological report to get more information but radiologist can and do miss foraminal compression.

https://neckandback.com/conditions/missed-diagnosis-far-lateral-lumbar-disc-herniation/
https://neckandback.com/conditions/foraminal-collapse-lumbar-spine/
https://neckandback.com/treatments/emgncv-electromyograms-and-nerve-conduction-studies/

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.

[Meri]

#29415

Hi Dr. Corenman, and thank you for your help and the links. I did see a neurologist who immediately told me that I had Piriformis Syndrome and gave me 12 TPI, though both sides of my buttocks felt basically the same when he was palpating them. Following that, my symptoms continued to worsen and I had an upright MRI, though it was ordered without positioning (which exacerbates the pain), which showed at the L4-5 level “forward slippage resulting in 2mm of uncovering of the disc space posteriorly. Advanced degenerative facet arthrosis. No significant narrowing of the central spinal canal. Slight narrowing of the anterior-inferior foraminal recess on the left. No nerve root impingement. I expected, based on the severity of symptoms, that I had herniated a disc. Could those results be responsible for my continued radicular symptoms? Thanks.

[Donald Corenman, MD, DC]

#29419

You most likely do not have piriformis syndrome. I have seen maybe 3-4 cases in my lifetime over 10’s of thousands of patients. You do have a slip at L4-5 (the most common level for a slip) with severe degenerative facet disease (which also goes along with this disorder). Have you had standard flexion/extension films where you are asked to flex as far as you possible can? You could have an instability at L4-5 which only compresses the nerve root when you move in a certain way.

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.

[Meri]

#30067

Appreciate your advice. I was finally, following the last MRI, able to be referred to a surgeon who did flexion/extension xrays and noted a 7-8mm slip. As I’m a year and half into this and conservative treatment has failed, I am scheduled for a TLIF with decompression in March. Hoping it helps. Thank you again.

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