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Dr. Corenman,
I have just received MRI report and would like your opinion on whether I can avoid any type surgery with proper rehab. I am 45yo male, average physical shape for former athlete, 5′ 9″ 185 lbs, poor core strength, self employed CPA, restaraunt owner, land business. Spend 85% of time in a vehicle, at desk, or in bleachers watching daughters play basketball.Veterbral heights preserved. No subluxation is seen. Fairly advanced desiccation of L3-4, L4-5, and L5-S1 discs. At least mild loss of height at L5-S1. Modic type II endplate degenerative changes seen at L5-S1. No area’s of significant soft tissue or bone marrow edema are identified.
Axial imaging begins along inferior margin of L1 level. No significant disc bulge or thecal sac stenosis is seen above that level on the sagittal imaging.
L1-2: No significant disc bulge. No significant stenosis.
L2-3: same as L1-2L3-4: Some diffuse bulging of disc. Superimposed upon this is a component of slight right paracentral disc extrusion with some inferior migration of the disc material. There is mild impression of the ventral thecal sac which is most prominent in the right paracentral area. There is moderate degenerative facet arthrosis. Thecal sac is mildly narrowed w/ central AP dimension estimated at 1cm. The foramina remain reasonably patent.
L4-5: There is some diffuse bulging of the disc including a small to moderate broad posterior component. This causes mild impression of the ventral thecal sac without significant thecal sac stenosis. There is moderate degenerative facet arthrosis. Mild narrowing of the neural foramina.
L5-S1: Some diffuse bulging of the disc of fairly mild degree. Superimposed upon this there appears to be a small component of left paracentral disc extrusion with slight inferior migration of disc material. The disc material is in close relationship to the left S1 nerve root in its exit zone. No clear impingement is seen. Correlate clinically. the thecal sac remains reasonably patent at the level. There is moderate degenerative facet arthrosis. There is moderate left and mild to moderate right foraminal narrowing.
IMPRESSION: Multilevel degeneration in the lumbar spine as detailed above. This includes mild thecal sac stenosis at L3-4. Also of note, a small lefet paracentral disc extrusion component at L5-S1 migrates inferiorly where it is in close relationship to the left S1 nerve root. Correlate clinically.
END Report —
I have always had low back pain that comes and goes. About two months I got in a hurry and moved a freezer by myself and although I didn’t feel any immediate pain, I began a day or two later began feeling sore and tight. Then slowly the left buttocks and hamstring began burning, then a little later the outer left calf and some outer left foot. Pain increased. After about 2 weeks went GP. He put me on oral cortosteroid pack for a week. some relief but pain came back after pack ran out. Then began Zipsor 25 mg three times a day for three days, then twice a day as needed. The Zipsor takes the edge off of pain, but after about 5 – 6 hours comes back. I have begun mckenzie strecthes, priformis muscle stretches, and moved Zipsor back up to three times a day and 1 Tizanidine at night before bed. Pain is tolerable if I don’t aggravate by driving longer than 30 minutes. Pain is pretty tough upon rising in the morning (why the morning?). Have to really take it is easy on left leg until after showering, wife and daughters are rotating helping with socks and shoe tying. After I get moving and about 45 minutes after Zipsor I am pretty good.
Dr. Corenman, Can I whip this thing with a program of rehab i.e. traction, stretching, and core work? and how bad a shape is my back in?
Have been debating injections. Would like your thoughts when you have time. I know your are extremely busy and I am thanking you in advance,
First issue to understand is that the MRI findings have to correlate with your symptoms. There are many individuals with significant MRI findings and no symptoms.
You have had intermittent lower back pain. If you did not have leg pain, would you seek treatment for this pain or is this pain manageable? The lower back pain is caused most likely by your degenerative disc disease at multiple levels but your L5-S1 disc is the worst by report.
The leg pain is most likely radiculopathy from nerve compression. You have two potential sources of leg pain, the left herniated disc at L5-S1 and the foraminal stenosis at the same level. Herniated discs typically cause sitting pain that is relieved by standing and foraminal stenosis causes the exact opposite- pain with standing relieved by sitting. By your report, you have sitting pain so most likely, the pain source is the L5-S1 herniation.
For nerve pain from herniated discs, a rehab program by a skilled therapist and an epidural injection would be the next step in my practice. Depending upon how long the symptoms were present, there is about a 70% chance of obtaining good relief with that program. The injection would be followed by a pain diary (see website) so that if the injection gave good temporary relief but no long term relief, the surgical diagnosis would already be made.
If no relief from the above program, there was motor strength deficit or the pain was quite significant, a surgical discussion would be undertaken with all the benefits and risks involved.
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.Dr. Corenman,
I appreciate the time you take to provide this forum. You have my mri results above and I have now been twice to rehab at physical therapist.
Rehab consists of 20 minutes stretching include prone arm extensions arching backwards, 20 minutes traction table with harness/electrical motor contracting and expanding. Finish with 20 to 30 minutes of deep massage in low back and electrical stimulation of nerves. 3 days week.
I am taking Zipsor 25 mg four times a day with reduction of approximately 85% of pain for about 4 to 5 hours with each pill.
I cancelled my third rehab visit today, because I am afraid the traction may further damage one or both of my extruded discs.
As I stated earlier, I have had low back pain for years but about two to three months ago I think I overdid it moving a freezer. The left leg pain began a couple of days later and has continued. Oral steroids gave a little relief. If I quit the zipsor the full pain returns.
My questions are: Is the traction table appropriate for my type of extrusion? In general what type of rehab would be appropriate and for how long should I attempt rehab before I risk damage to the nerve permanently? Do injections reduce inflammation or just deaden nerve and risk permanent nerve damage from normal daily activities?
Please forgive me if I have asked to much at one time. I am willing to pay and would like to send you a copy of the cd with mri images if possible. Thank you Dr. Corenman.
The purpose of rehabilitation is to have the therapist teach you to strengthen muscles, stretch joints and the spine and to teach you ergonomics (how to lift, bend and what activities to avoid). It sounds like you are in a program that is palliative (relaxing the muscles but no real rehabilitation).
The program you are currently in will make you feel better for an hour or two after but will do you no real lasting good. You need to come out of a rehab session feeling like you had a significant work-out. There are therapists who specialize in spine care and you need to find that individual.
Injections are the one of two treatments (rehab is the other) that can make a difference in many patients. I cannot predict how long the injection will last but steroid on a nerve root can change the inflammation pattern and give long lasting relief.
I do review MRIs and X-rays. You can call (970) 476-1100 and ask for DIana or Sarah.
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.Thank you. I have spoken with Sarah. Do you think the mechanical/motorized tractio n table is ok for an extruded disc? I have a rehab appointment Friday. in your previous post you referred to 70% chance for relief. Does that mean no surgery or just putting off surgery for a few years. I know you don’t have a crystal ball, but in general. Thanks, Michael
In general, 70% of patients with a herniated disc without motor weakness will not need surgery. I give my patients three months to improve with therapy and injections. If there is not significant improvement in that time, we discuss surgery.
The traction device can yield temporary relief but I have seen a small handful of patients get worse on this device.
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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