[sheray]

#8724

Dear Dr Corenman,

Thank you for a most excellent and informative website and forum.

I have been suffering from sciatic pain down the back of my right leg for about a month now. I have had backache issues over many years. The pain comes and goes but has been better over the last year or so since I started working out and losing weight. My backache was mainly lower back, right of centre.

PAIN / PERCENTAGE / INTENSITY / WEAKNESS
The sciatic pain starts at the right buttock, down the hamstring, behind the knee and down the calf. The pain is not at all those areas at the same time, but is often at the hamstring area and at the other areas mentioned down the leg at different times. Pain is most prominent when I stand up after sitting down. There is a sharp pain mostly at the hamstring area and I have to clutch it tight for almost 15 – 20 seconds in order to calm it down. Once the pain subsides, walking is only mildly painful, although there is sometimes a slight pain / pull. There is no lower back pain. The pain, therefore is around the 70 (buttocks / hamstring) / 30 (leg) range. I do not feel I have any numbness on the soles of my feet. I may have a slight weakness or limp but that, I feel, is more due to the pain.

I cannot bend forwards to touch my toes without there being a sharp pain down the right leg. I can’t keep my right leg straight when I bend as such. Coughing or sneezing results in a sharp shooting pain mostly in the hamstrings area. I would say the pain using the VAS scale is around 6 -8 when I first stand up after sitting down or when I have moved into a twist or a position that stretches the leg in a way I cannot do so for now. Therefore, the pain is sharp at that stage.

Sitting is not very painful, although the hamstring area still has some bearable pain. There is just the discomfort factor.

ACTIVITIES
Until about 10 days ago I was running at a slow pace on the treadmill. It got progressively more painful so I have had to stop that. I still try to cycle (stationary), which is more manageable and walk. I have also now started some swimming.

TREATMENT
When the pain first started, I went to see a physiotherapist a few times, for TENS, ultrasound and heat massages. These help but only briefly. I then went for an MRI, the results of which are :

– Straightening of the lumar lordotic curvature. Small marginal osteophytes seen at multiple levels.
– Minimal retrolisthesis of L5 vertebral body.
– Degenerative disc desiccation seen at multiple levels. Mild left foraminal disc portrusion at L3-L4 and L4-L5 level, indenting the ventral thecal sac and compressing left exiting L3 nerve.
– Marked right paracentral disc extrusion at L5-S1 level, effacing ventral epidural fat planes, attenuating the right lateral recess and markedly compressing right descending S1 nerve with moderate compression of right exiting L5 nerve as well. Mild bilateral foraminal compromise also noted at this level.
– Tarlov’s sacral cysts noted at S2 vertebral level.

The conclusion of the MRI is :
– Mild left foraminal disc portrusion at L3-L4 and L4-L5 level.
– Marked right paracentral disc extrusion at L5-S1 level.

I went to see a neurosurgeon about the MRI findings and I was told that the extrusion at L5-S1 means that a part of the disc has “broken away” from the disc and it is that extruded part that is compressing the nerve and causing the sciatic pain.

I was advised the options I have are conservative to start off with (medication), and if not successful then injections and finally surgery.

A week ago I was put on Gabanerve (Gabapentin – 300mg & Methylcobalamin – 500mcg) Tablets, twice a day. I have had no significant benefit in terms of pain reduction and I have now been advised to take Lyrica 75mg twice a day instead of the Gabanerve.

I am also still seeing the physiotherapist a couple of times a week.

I would respectfully request your opinion or advice on the above. The pain has “taken over my life” and I cannot enjoy the things I used to. I can send you a couple of pictures of the MRI scan showing the extrusion at L5-S1 if you would like to see them.

Thank you very much indeed.

[Donald Corenman, MD, DC]

#8725

You have classic findings for a herniated disc at L5-S1 on the right. The other disc bulges (at L3-5) are not symptomatic so don’t worry about them.

The reason you have pain with transition to standing is that the nerve actually has to move (like a cable over a pulley) and becomes “caught” in the pulley temporarily. When you bend over, the nerve is pulled against the mass of the disc herniation and hurts.

If you have no motor weakness (which should have been revealed by a thorough physical examination by the neurosurgeon), then you are on the right path. The next step after four weeks of failed physical therapy would be epidural injections of steroid. If these are effective, then you should be able to function relatively normally.

If these are ineffective, then a microdiscectomy would be the next step. See the section regarding “when to have lower back surgery” to understand the conditions for surgery.

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.

[sheray]

#8726

Thank you very much for your time and reply Dr Corenman.

The neurosurgeon did not actually check on motor weakness but just asked me if I felt any weakness. I am unsure if I have any weakness or if the slight limp is caused by pain. I don’t feel I have any drop foot issue. Are there any particular tests that should have been conducted to determine weakness?

The concern I have is that with medication or, if I need injections later, as this will not be targeting the root cause of the problem in that the nerve may still continue to be “rubbed” against the herniated disc, then even though the pain is masked, would the nerve not continue to be damaged thus resulting in probable irreversible damage?

With thanks.

[Donald Corenman, MD, DC]

#8729

Did this neurosurgeon not do a physical examination? If not- find another neurosurgeon. Some physicians too lazy not to do the basic requirements to determine diagnosis do not have the necessary information to make a diagnosis and propose treatment.

I understand that you want this disc hernation out but with no motor weakness, 70% of patients will get better without surgery. If however, you do have weakness (which is why the examination is so important), I generally recommend surgery. I think that 6-8 weeks of treatment including epidurals is enough time to determine if surgery will or will not be necessary.

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.

[sheray]

#8732

Thank you again Doctor Corenman. There was a brief (1 minute or so) examination but rather than checking on any weakness, I was just asked if I feel any, and I can’t quite differentiate between the pain and the weakness. I will seek another opinion locally as you have suggested.
I will give the medication a few weeks and see what happens. Fingers crossed!

[Donald Corenman, MD, DC]

#8733

Please let the forum know what your progress is.

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.

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