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  • Ahmed Ali
    Member
    Post count: 5

    Straightening of lumber spine curvature noted.

    There is mild anterior subluxation of L5 over S1 vertebral body with bilateral L5 pars interarticularis defect noted (grade 1 L5-S1 spondylolisthesis).

    L2-L3 disc shows mild posterior annular bulge with preserved signal intensity causing flattening of ventral dural sac.

    L3-L4 disc shows mild disc bulge with preserved singal intensity and minor central protrusion causing mild indentation on ventral thecal sac.

    L4-L5 disc shows loss of normal T2 bright signal intensity and diffuse circumferential disc bulge with right posterolateral right osteophyte complex encroaching right lateral recess causing left L5 lateralstenosis.

    L5-S1 disc shows earlyloss of normal T2 bright signal intensity, diffuse disc bulge with annular tear and small broad based left posterolateral disc protrusion encroaching left L5-S1 neural foramina lying in close proximity to left L5 exiting nerve root.

    Rest of the visualized intervertebral discs are preserved.

    Rest of the visualized neural foramina and exiting nerve roots appear normal.

    Modic type 2 endplate degenerative changes noted at L4-L5 disc level and T12 superior endplate.

    Small Schmorl node is also noted at L3 and L4 vertebral body.

    Rest of the visualized vertebral bodies appear normal in vertical height, alignment and marrow signal intensity.

    Rest of the visualized posterior elements including facet joints and ligamentum flavumare intact.

    Conus and caude equina roots appear normal.

    Thecal sac elsewhere appear normal.

    Pre and paravertebral soft tissue appear normal.

    IMPRESSION

    Mild L5-S1 spondylolisthesis (grade 1).
    L5-S1 disc desiccation with diffuse disc bulge, annular tear and small left posterolateral disc protrusion encroaching left L5-S1 neural foramina lying in close proximity to left L5 exiting nerve root.
    L4-L5disc degeneration with diffuse disc bulge and right posterolateral disc osteophyte complex encroaching and compromising L5 lateral recess.
    L3-L4 diffuse disc bulge with minor central protrusion.

    thanks you.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8459

    It is important to note symptoms to compare to any imaging. There are findings on imaging that might cause symptoms but there are times that even with significant pathology on imaging, no symptoms are generated. See the section on how to describe symptoms to understand how to convey your problem on the internet.

    The MRI notes a spondylolisthesis at L5-S1 but the radiologist does not identify the slip as isthmic or degenerative (the most common at this level is isthmic). This disorder can cause lower back pain.

    The L5-S1 nerve root on the left is compressed. This can cause buttocks and leg pain especially when standing and walking.

    The L4-5 disc is significantly worn “Modic type 2 endplate degenerative changes noted at L4-L5 disc level”. This can cause lower back pain.

    Dr. Corenman

    Ahmed Ali
    Member
    Post count: 5

    Dear Dr. Croenman,

    please find below as requested.

    Location and Quality of Pain

    What is the quality of the pain?
    The pain is in the lower back into buttocksto wiastline and radiating to thigh and leg left, right or both sides with burning, dull and sometimes aching.

    Does the quality of pain change with activity?
    Yes, Increases while sitting radiates to thigh and leg. Also increases when standing, less while sleeping, but have to change position or will have difficulty in getting up.

    Is the skin hypersensitive to touch?
    No hypersensitive, but sometimes yse.

    Are there associated skin changes like thickening, color change or nail changes? This is important in the foot and lower leg?
    No.

    Percentage of Pain by Location

    What is the percentage of pain in the back vs. buttock and leg?
    It 50% back vs. 35% buttocks 15% thigh and leg.

    Intensity of Pain

    The current pain back & buttocks is 4-6 VAS.
    Leg now is now 0-2 VAS.
    Thigh now is 0 VAS.
    The worst befoer 7 years 9-10 VAS. Radiating from back to thigh to leg right side.

    Weakness

    Is there weakness associated with the pain?
    sometimes, not always.

    Is the weakness due to pain inhibition (the muscle is weak from use due to pain) vs. neuropathic weakness (is muscle is weak because the signal from the brain is interrupted due to a pinched nerve)?
    Don’t know.

    Is there now a limp due to pain or to weakness?
    Sometimes.

    Are certain activities more problematic like climbing stairs (due to weakness and not pain- such as a weak anterior thigh muscle) or walking due to a foot drop (you catch your toe on the ground when you walk) or even push-off (your foot will not push you forward while you are walking)?
    No.

    Onset and Length of Time Symptoms Have Been Present

    How did the pain start?

    Was it a gradual onset over years or was there one specific activity or injury that caused it?
    Always present over years, but increases sometimes.

    When did that injury occur?
    7 years ago.

    Describe the activity or action that brought on the pain. Was it a lifting injury, a bike accident or did the pain onset come on gradually?
    lifting some heavy.

    How long have the symptoms been present and have they changed in quality or intensity?
    The pain is present since 7 years on and off.

    Activities

    What activities increase or reduce the pain?
    Increases is Joging, otherwhise pain is always present but in lower level and increases for no reason known to me.

    Think carefully about this question as the information produced is very valuable: Is it sitting that increases the pain where standing reduces the pain or visa versa?
    Both.

    Can you sit for 15 minutes or one hour before you have to get up?
    yes, but painful.

    How far can you walk?
    maybe 2 miles.

    Does prolonged exposure to the activity cause more pain?
    depending on the activity.

    What does bike riding, sitting, standing, walking, lifting, jumping, computer work, driving or flying do to the pain?
    Sitting, standing and jumping in general make pain worse. Walking is less but when I stop it pains.

    Does the activity cause different symptoms?
    Not sure.

    Does the lower back hurt with sitting and bending but the leg hurt with standing and walking?
    Back and leg hurt with sitting and standing.

    Does the neck pain become worse with bending forward vs. backwards?
    Yes, sometimes.

    Is there instability pain? That is, is there only mild pain with activities that becomes excruciating with a certain movement that you avoid like the plague?
    There IS mild pain with activities that becomes excruciating with a certain movement that I avoid.

    Does daily function go relatively smoothly unless you bend over to pick something up?
    Yes, but I avoid certain movements.

    Pain Intervals
    •Are you pain free for certain times of the day or with certain activities?
    sometime, but have pain with sitting, standing. Maybe the pain is mild with walking but severe with sitting. Possibly there is moderate constant pain that becomes severe with, jumping or some other activity like running.

    Are there flair-ups that occur? Are you pain free for most of the day but by the end of the day, pain onset occurs? Do you get pain crises? Are you free of pain for a week, month or even year but one event will cause severe, incapacitating pain?
    Pain is always present but on a lower level, but flair-up for no reason or any activity.

    When the pain crisis occurs, how long does it last?
    Depending when I visit the hospital, generaly 3-4 days.

    Activity and Occupational Restrictions

    How has the pain changed your life?
    Walk and move very carefully.

    Have you adapted to the pain by limiting your activities? If so, what activities do you now avoid?
    Yes, running suden movements.

    Do you no longer participate in recreational activities that you once did? Which activities have you eliminated?
    Yes, running .

    What activities have you modified?
    Now walking & swim vs. running for 45 minute a previous.

    What do you now do to prevent pain from occurring?
    Don Know what flairs up the pain to avoid reoccurring.

    What type of work are you involved with?
    Expediting company work in other companies and gernment departments. involves driving, standing and office work.

    Describe your work by its physical demands. Do you have to repeatedly lift, bend and twist?
    No lifting or twisting.

    Do you have to sit without position change for long periods of time?
    Yes, Sometimes.

    Are you off of work due to the pain or did you have to change your job position secondary to pain?
    Same job, but I try to avoid sick leave as much as I can.

    How long have you been off work or have changed your position?
    In general Sick leave is for 3-4 days.

    Liability
    •Is there liability from another party (motor vehicle accident or workman’s compensation involved)?
    Both motor vehicle accident or workman’s compensation involved

    Have you been injured by another’s fault?
    Recently I was involved in an accident on 3/June/2012 no direct hit to me but bad damage to my car. Pians have increased and symptoms have changes. Prevously only pain in back radiating to right side.

    Liability is too complex to be dealt with by a simple Internet site. Your consultant will need to obtain specific details regarding the injury to help with any decisions on settlement or causality and apportionment.

    Previous Consultations or Treatment

    What previous treatment have you had?
    Yes.

    Have you seen a chiropractor?
    yes.

    Have you seen a therapist?
    Yes.

    How successful or non-successful has that treatment been?
    On and off.

    Have you seen a surgeon and if so, what did they say?
    Some said surgery others said you can wait.

    Did you have previous spine surgery and if so, what procedure?
    No.

    What happened to your symptoms with the prior surgery?
    No Surgery.

    Again I thank you for your time and effort.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8459

    By the description of your pain, you probably have lower back and leg pain from the spondylolisthesis at L5-S1 but might also have pain generated by the L4-5 level also. Without significant weakness or bowel/bladder involvement, the surgeons you have seen have given you correct information. There is no emergency here for surgery.

    Nonetheless, with the length of time of your symptoms, extent of treatment and day to day impairment you note, you could consider surgery. You have to understand what surgery will and will not do for you.

    If a thorough work-up including a physical examination, review of all imaging, possible nerve blocks and/or discograms confirm the pain generators are at L5-S1 and possibly L4-5, you could be a candidate for a one or two level fusion. This has a high probability of relieving 2/3 of your back pain and most of your leg pain.

    You do have mild degeneration of the discs above at L2-3 and L3-4. This means you could be relatively pain free after surgery but could not join the US Olympic team. The discs above could tear in the future and cause new onset lower back pain so you would have to reasonably careful. The surgery results are all about expectations. If you want to live a relatively pain free life with no heavy work in the future, surgery could be very helpful to you.

    If you want to retune to tennis, brick laying, heavy gardening or other heavy loading of the lumbar spine, surgery would not be a good idea.

    Dr. Corenman

    Ahmed Ali
    Member
    Post count: 5

    Hello Dr. Cornman,

    Thank you for your reply, but I have several more questions.

    1. Can my condition deteriate more if do not go for surgery? And if so what are the deteriation I will face?
    2. If I do go for surgery what can I expect? Will they be restriction in movement or any other? Rate of the success of the surgery?
    3. My job consist of driving, standing or sitting for long times will this creat more problem or deteriation of my back?
    Finally what do you advise.

    Thank you for all your time and effort.
    Ahmed

    Donald Corenman, MD, DC
    Moderator
    Post count: 8459

    Your condition can continue to degenerate but there is only a slight chance that a severe flair-up will cause substantail increase your pain. Generally, pain waxes and wanes and your activity level will be in command of the intensity of your symptoms.

    If you only needed a one-level fusion, you would not notice much if any restriction of range of motion. A two level fusion causes more need to restrict activities. Due to your mildly degenerative discs above, twisting impact activities might cause symptomatic upper level disc degeneration. Sports like tennis and skiing should be restricted if a two level fusion is necessary.

    Driving, standing or sitting generally does not cause significant loads on the back.

    See the section on “When to have lover back surgery” on the website to understand timing of surgery.

    Dr. Corenman

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