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It seems your current problems are two. The most pressing issue is the degenerative spondylolisthesis at L4-5. This has caused significant central and bilateral foraminal stenosis. By your report, this is “stable” (it does not move on flexion/extension films).
What are your main complaints? See the section “How to describe symptoms” to fully convey your current symptoms. Read carefully to differentiate central back pain from SI, buttocks and leg pain.
If you have severe weakness of your gastroc/soleus group and it has been over a year, it is unlikely that you will have return of muscle function. See the section “How muscles recover from nerve injury” to understand this concept.
I am glad you are not going to have “laser surgery” as this is generally ineffective and can be dangerous on occasion.
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.Spine injury symptoms
Location and Quality of Pain
Pain usually starts first in lateral calve of right leg area at a quality of 8. The pain will radiate into lateral ankle of right foot. If pain builds long enough in calve then pain will also kick in to right side of spine in area of L4-5 at quality of 6; strangely not L5-S1 because I can match up with incision line. Lastly, pain will migrate to right gluteal area at quality of 4. Now within last 4 months, I have been experiencing some sporadic pain at bit higher than L4-L5 at quality 3 in center of spine and that triggers some burning pain in left quad at quality of 2 and quick sharp electrical pain in left medial calve and left medial foot.
Pain in right calve is burning and gnawing. Pain in right foot is switches from stabbing to pins and needles. Pain in right side of spine is stabbing. Pain in right gluteal area is aching. Pain higher than L4-L5 is electrical shooting and pain in left anterior quad is burning. Pain is sharp and shooting in left calve and left medial foot.
Quality of pain changes when I am exercising and I can stretch it away. I can eliminate the pain usually with extension movements of the leg, lower back and core stabilization movements. Also lying down on back or sitting in Indian style legs will usually release pain instantly or within several minutes. Standing and sitting at computer work for 30 mins+ will usually set the pain in right calve off and then in injured disc area.
Skin is sensitive to squeeze or massage pressure in the medial right calve where majority of muscle atrophy has taken place; also back of right knee joint.
No associated skin changes anywhere, although the right lower leg and foot will be cooler than left leg even during intense exercising.
Percentage of pain is in lower right calve is 80%, back is 10%, buttock 10%. Left anterior quad burning and electrical sharp pain shooting in left calve and foot is sporadic; not there on a regular daily basis. However, I know the left quad is weaker because as I perform lunges with weight, the left quad action becomes weak to quick and develops a burning sensation. The right quad performs strong during lunges compared to left quad and this was not happening prior to discs herniating.
Intensity of Pain
Right lateral calve = 0-10 VAS
Right lateral ankle = 0-6 VAS; sporadic
Right posterior knee joint = 0-8 VAS; sporadic
Right side of L4-L5 = 0-6 VAS
Right gluteal = 0-4 VAS
L3-L4 area = 0-2 VAS; sporadic + quick
Left anterior quad = 0-4 VAS
Left calve = 0-4 VAS; quick to hit and leave
Weakness
Right calve very weak; almost to none plantar flexion
Right hamstring weak and numb areas
Right gluteal weak and numb areas
Left posterior quad weaker than right but no numb areas
Left calve not weak (yet) and full plantar flexion
In addition, I can walk on heels on both feet for distance.
I have slight limp in right; however, it was quite worse.
Onset and Length of Time Symptoms Have Been Present
In 2008, I flipped off a low bridge into a gully while trail bike riding; bridge wood was rotten and bike tire broke through it. I tore partial right hamstring; not enough to have reattachment. I rehabbed hamstring for several months. Upon getting back to trail running a year later; I experienced electrical pains switching between feet. I went back to Ortho group for evaluation; I was sent to Ortho foot doc. Making the story short, Ortho foot doc disagreed that pain could be stemming from lower back injury, refused MRI on back, put me on anti-inflammatory and gave me heel orthotic to switch between whichever foot was having pain. Really? I went back a few more times explaining pain still occurring. Perhaps I should stop running, he said.
In 2011, I was opening gym locker room door and experienced a jolt of electricity from right leg and up through spine. I fell on floor and could not stand up on leg for 10 mins or so and severe lower extremity pain and weakness continued. Since I have physician clients, I called one and he got me an after hour appointment with Dr. W at Semmes Murphey Clinic, Memphis. Dr. W evaluated with lumbar spine MRI and diagnosed ruptured L5-S1 and disc bulge of L4-L5; treated with medication and PT. I went back to Dr. W within several months asking for second MRI to evaluate situation. I was told I just may have to change my lifestyle and live with the pain.
On July 7, 2011, I was sitting on back seat of golf cart as passenger and driver turned cart to fast and sharp and threw me off back seat onto pavement. I struck back of head and back on pavement. That incident caused increased pain in back and more weakness in right calve.
My physician client recommended new doc, Dr. P. After new MRI, x rays, epidurals, nerve conduction assessments, surgery was performed in 2012 only on L5-S1 extruded disc. L4-L5 bulge was not touched and at this time, neither doc had seen L3-L4 bulge. Not sure if L3-L4 bulge was there because it is very small on each side of spine. Upon showing my Oct 2014 MRI to Dr. P, he still did not see L3-L4 bulge, I had to point it out to him. I also took this Oct 2014 MRI to Dr. W consultation where he looked at Dr. P’s work on L5-S1 and acknowledged L4-L5 still bulged with nerve compression and L3-L4 tiny bulge. Dr. W said he still would not touch me and Dr. P gives no advice on the risk/reward of surgery on L4-L5. Dr. W gave an annoying comment of me not accepting that I have bad genetics. ? It could not have anything to do with being a competitive bodybuilder, snow boarder, and athlete or many years.
ActivitiesLower back injured disc area hurts with sitting with slight flexion and standing. Lower leg, calve area and sometimes lateral ankle hurts with standing still, sitting with slight flexion and regular walking for 30 mins or more. I feel the best and no pain when I am consistently active, such as working out, except I eliminate lifting in flexion ~ that is a big no no. When the pain from walking or standing becomes great, I can release the pain by sitting on floor and stretching out the gluteal area, or having the glutes and my core muscles contract. I can also rid pain by holding myself in straight arms and on toes push-up position with controlled, tight core and then alternate repetitions of slightly lifting off floor one leg and opposite arm. I alternate my physical fitness training between bike, elliptical and hill walking on treadmill and resistance training different muscle groups. I have minimal pain with elliptical and tread walking and no pain with cycling. If I am to push weight over my head while standing or sitting straight I can have nerve pain that can be in lower back or right calve or both at same time. I have modified my resistance training to be at spine angles that does not cause pain.
Working out with the spine tilted back works much better. On my busy days of training eight or more clients, right calve pain usually kicks in by about 4:30. On those days it will continue on through preparing dinner at 8 pm and then I can work it out by sitting Indian style while eating dinner.
Pain intervals
Some days I can be pain free until later afternoon, however, some days the pain can begin as soon as my feet touch the floor out of bed. I also can get severe charlie horse muscle cramping in right leg or both legs same time while lying in bed sleeping. I notice I can instigate the Charlie horses to strike by performing a full body stretch in a lying position with my arms stretching over my head. However, the charlie horses will not arise if I stretch my legs without reaching my arms over head.
The pain in the lower right calve is always the worse of other areas. It occurs at same pain scale in sitting or standing. There is not a day in four years that I do not have pain at some time in the right leg.
My career and passion is being a Health/Fitness Professional Trainer. I own an exclusive fitness training center for 14 years and an online exercise company for one year. I am a very active, competitive individual and I realize I will never be 100%. However, being in tune with my body, I believe that more repair is required for my body to be given a full chance to heal.
I am thankful of your time.
Best,To summarize;
Right leg pain-calf pain (majority of pain at 80%) at 8/10 into lateral right foot. Burning/stabbing right gastroc/soleus weakness of 1-2/5 (very weak)
Can “stretch the pain away” with extension. Standing and sitting increase pain.
Occasional Left thigh pain at 2/10
Left quad “weaker”2011 when severe right leg pain and weakness developed. Noted extruded HNP at L5-S1. Microdiscectomy at L5-S1(?) about a year later. Still continue with leg pain and weakness.
You have mentioned in the past that you have a slip at L4-5 with central stenosis.
Putting this all together without having an MRI and X-rays is difficult but here goes.
You had an injury to the right S1 root with your disc herniation. The nerve was damaged (you have continued weakness of the gastroc/soleus on the right with continued pain even after decompressive surgery). However, with positions you can adopt that relieve pain, this means that there is still some ongoing compression of this nerve that possibly could be removed surgically to at least reduce this leg pain. After one year without strength return, you will not have normal motor function return of the calf muscle.
You have a degenerative spondylolisthesis of L4-5 with central stenosis. This might be affecting your left L4 nerve root to cause leg pain and weakness of the quad muscle.
Positions that effect pain are a question. Normally, with stenosis, flexion improves pain and extension aggravates pain. With a continued disc herniation, flexion aggravates pain and extension improves pain. You might have both continuing so that there is not a standard pattern of positional pain.
You need a careful evaluation by an experienced spine surgeon to fully elucidate what problems you have. This might included further MRIs, new EMG/NCV testing and possibly a CT scan. A thorough physical examination should of course be part of this evaluation.
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.I am a 47-year old female, 6’1″, average weight for my height, with a history of Mixed Connective Tissue Disease, Raynaud’s, and am on warfarin for the remainder of my life I have been told. I have severe pain in my lower back, into my right hip, which at times feels like it will dislocate, and now the pain seems to be radiating to my left hip, and down the front and back of the right leg, though normally the pain is either in the front or back of the leg, not normally both at the same time. When I stand for 10 minutes or longer, the pain feels like it is under my ribs, almost to the point of not being able to breathe, and it’s like gravity is exerting intense force on my back and ribs. Often when I bend forward my back pops, but not like someone normally pops their back,it’s more like something sliding into or out of position. It hurts at times when it does that but not always. I have been to an orthopedic spine specialist who has referred me to pain management, and I am concerned that I am going to be simply masking a problem instead of trying to correct or prevent something worse happening in relation to my spine. I can’t sit, stand or walk for more than 10 minutes at this point, there is an electrical type pain that radiates when I turn or twist my spine in any way, all lower back. These are the MRI results, I do not understand them, my physican did not go over them, and I would like to know if it would be beneficial to me to see other treatement either with a neurologist or another spine specialist. Thank you.
MRI Lumbar Spine:
Lumbar Spine: For the purposes of this study, there are 5 nonrib-bearing lumbar-type vertebral bodies. Lowest fully segmented body will be labeled L5. Using this numbering system, the conus terminates at the level of T12-L1. The conus and cauda equine nerve roots appear grossly unremarkable. On the sagittal images, reactive Modic signal is scattered throughout the lumbar spine especially within endplate surrounding L2-3 and L5-S1. No acute fracture seen.
L1-2: Normal
L2-3: Circumferential disc bulge is present along with bilateral ligamentum flavum redundancy. There is mild central canal narrowing at this level. Neural foramina are patent.
L3-4: Mild circumferential disc bulge is present along with bilateral ligamentum flavum redundancy. No stenosis.
L4-5: Bilateral facet hypertrophy. No central canal narrowing. There is mild bilateral neural foraminal narrowing at this level.
L5-S1: Bilateral facet hypertrophy is present. No central canal narrowing. There is moderate left and mild right neural foraminal narrowing.
Tarlov cyst is seen posterior to the sacrum on the sagittal images. Evaluation of the soft tissues does not demonstrate any focal abnormality.
Impression: Multilevel degenerative disc and facet disease with no high-grade central canal narrowing. Details of each level as above.
By your description of symptoms, you could have isolated disc resorption at L5-S1 (and even at L2-3). You have significant degenerative facets at L4-5 and L5-S1 so that could be an indication of degenerative spondylolisthesis at either of these levels. Instability can be associated with these diagnoses.
You have foraminal stenosis at L5-S1 and even somewhat at L4-5. This could be causing your leg pain.
See each of these diagnostic topics on the website to better understand what these mean and if your symptoms match any of these disorders.
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 so very much for your response. I see pain management tomorrow, and will be researching if I should see a neurologist or an orthopedic spine specialist. Since this is also in my cervical spine I’m just at a loss on options. Thank you again,many happy holiday’s!
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