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  • derrick004
    Member
    Post count: 3

    Thank you Dr. Corenman for this invaluable website for people like me thats been suffering for years of debilitating back pain. Been lurking around here and finally posted something . Not a stranger to back problems, having it for the last 25 years off and on. Seven years ago, I was diagnosed with a DDD. Epidural injections are the only thing that works for me. I get it about once a year (series of 3 shot), it gives me about 10 months to about a years worth of pain relief. I got 2 MRIs total, heres the latest.
    MRI FINDINGS
    Degenerative disc disc is present at L4-5. L4-5 contains a small posterior annular high intensity zone. Disc height loss is most prominent at L5-S1 whre discogenic endplate changes are present. the vertebral bodies are maintained in height and allignment. The conus is normal caliber and signal.

    At L2-3,L3-4 and L4-5, there is no significant central canal or neural foraminal narrowing.

    At L5-S1, a 5-6 mm right paracentral disc protrusion causes narrowing of the subarticular right lateral recess and probably abuts the traversing right S1 nerve root. There is no significant neural foraminal narrowing.

    Doctor Corenman in your experience, would it be the size alone be indicative of a microdiscectomy?. The reason I ask is, the ortho that i saw 7 years ago did not want to operate because it was a small herniation(5-6 mm). In hindsight I’m kinda happy he didn’t operate on me right away. Secondly, How safe is epidural to your spine? I’ve been doing this for the last 7 years (21 total shots to the back) so far been lucky that it’s still working and the only thing that works. I get the L5-S1 transforaminal epidural to the right and sometimes bilateral.Thirdly I’m considering surgery (microdiscectomy) , The thing that stop from having one is that I read somewhere that microdiscectomy is not indicative for back pain but for leg pain. Is this true compared to your experience? My pain is in mainly the buttocks, lateral to my sacrum. I also lean to my left side about 25 degrees and and bend forward . Recently, I’m having a very little foot numbness. It’s the lateral side of my right foot, and sometimes when i wear socks I would feel my pinkie toe having a little spasm, very minute no pain at all, Back 100% Leg 0% (Pain distribution). Dr. do you think my L4-L5 is also a pain generator by just looking at the MRI results? When I get this episode of flare up because of the cortizone wearing off, it’s a hellish life. I’ve been very good with timing it . When I feel it coming, I’ll just call my pain management office and schedule for some shots. I can’t keep doing this forever tho. Dr. do you think I will benefit from a microdicectomy. My family, friends tell me not to have surgery because I will get worse,but there not the one living with this pain. By the way Dr., I have not seen any spine specialist since 7 years ago. Sorry for this long post, hope I don’t bore you with my life story. Thank you for your patience and thank you also for a speeedy response.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    You have 100% sacroiliac pain or pain lateral to the sacrum without leg pain. You do not mention lower back pain (area around the “small of the back” in the center of the spine at the beltline). You do not mention what side the sacroiliac pain is focused on. Is it right sided only or bilateral?

    Sacroiliac pain is the one area that can have multiple origins. This includes disc pain, nerve pain, facet pain, and sacroiliac joint origin in the order from most common to least common origin. However, buttocks pain (lower than the sacroiliac joint) commonly originates from nerve root compression.

    You have disc height loss with endplate changes at L5-S1. This most likely is “isolated disc resorption” (IDR) and one of the most common origins of back and sacroiliac pain. You also have a disc herniation at L5-S1 on the right causing some compression of the S1 root. This too can cause right sided sacroiliac pain and more commonly causes buttocks pain. The facet cannot be ruled out as a pain generator by your description.

    I am unclear regarding your leaning position; “I also lean to my left side about 25 degrees and and bend forward”. Is this a posture you assume to relieve pain or a position you are locked into (a list)?

    In general, sacroiliac pain or/and buttocks pain originating from the spine can be disabling and incapacitating but generally is not dangerous. If you can manage with the epidurals, that is not a bad way to go. I have patients out 15 years continuing to get epidurals with good success although these injections do become less effective over the years for many patients. I have seen relatively few problems with most patients continuing to obtain epidurals other than ineffectiveness.

    The question you ask is whether a microdiscetomy will be helpful. For lower back pain, the microdiscectomy surgery is about 50/50 in regards to satisfaction after surgery. However, if the compression of the S1 nerve is causing SI or buttocks pain, the success rate for surgery is closer to 90%. This assumes that the SI pain is on the same side as the herniation and a selective nerve root block temporarily eliminates the pain.

    If the disc degeneration of L5-S1 (IDR) is the cause of the pain, a microdiscectomy will not relieve the pain. The way to determine if the L5-S1 disc is causing the pain is with a discogram (see website). If the facet is causing the pain, facet blocks will reveal if this structure is the pain generator.

    Dr. Corenman

    derrick004
    Member
    Post count: 3

    It is mainly low back pain, location would be the top half of the gluteus maximus, 2 to 3 inches lateral of my sacrum and 2 to 3 inches lower than my belt line. It is not in the center of the spine, the pain is deep down inside the muscle of the top half of my gluteus maximus. The pain is right sided only.

    The leaning position is more of a posture to attempt to relieve the pain “I also lean to the left side about 25 degrees and bent forward. I don’t do it on purpose it just happen when the pain start. Laying down gives me a lot of relief specially when I lay down on my stomach , I can even do Mc Kenzie and try to exercise to alleviate some of the pain but it does not take the pain away.

    Dr. Corenman, In your clinical experience, how long does a microdiscectomy give you pain relief? Isn’t microdiscectomy will eventually undermine your disc and eventually lead to all sorts of problem in the future, ” more microdiscectomy and or fusion “. I guess Dr. I’m just afraid of any kind of surgery.
    I read somewhere in your Steadman Clinic website that you where originally from Southern California , Is there any doctor that you can recommend?, preferably L.A. area. Thank you again Dr. Corenman,

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    Unilateral pain deep in the gluteus muscle is more likely radicular pain from a compressed nerve. The leaning position could indicate foraminal stenosis (see website for description) as this position opens the foramen. McKenzie exercises (back extension position) should not relieve your pain if this disorder is foraminal stenosis as this maneuver narrows the foramen or lateral recess even more.

    The microdiscectomy is not the problem that “undermines” the disc. It is the original degenerative changes of the disc and the full annular tear that allows the nucleus to “squirt out” of this through and through tear. The real problem is related to genetics and activity.

    I do not generally recommend other physicians as I do not really know the quality of their work. Ask around. Get some word of mouth recommendations. Look up the surgeon on the internet. Look at this site for questions to ask the surgeon.

    Dr. Corenman

    derrick004
    Member
    Post count: 3

    Hi Doc, a quick update of my condition. On sept. 9 , oct. 3 I had an epidural injection (transforaminal). It didn’t work as i hope it would, so I saw a local ortho and ordered an MRI.
    MRI FINDINGS:

    T12-L1, L1-2 the intervertebral disc is normal.

    L2-L3,L3-4 the intervertebral disc, neural foramina and facets are normal.

    L4-5 there is loss of disc signal without focal abnormalities. There is mild facet hypertrophy and foraminal stenosis.

    L5-S1 there is loss of disc height and signal intensity with an irregular right sided disc extrusion which measures 14 x 6 mm in the axial plane x 10 mm in the sagittal plane. This compresses the right L4 root in the lateral recess. The exiting L5 root is not compromised. There is bilateral facet arthropathy.

    IMPRESSION:
    At L5-S1, there is a right sided disc extrusion compressing the right S1 root.

    I told the ortho my medical history and he did some test on me and in a nutshell he recommended fusion surgery . He said for sure L5-S1 and he said he would do discogram on L4-L5 to see if it’ a pain generator. By the way Dr. Corenman he also offered laminectomy but mention that it might be a temporary fix because the disc is already extruded( IDR ). He also mention about Hybrid fusion, fuse lower level and do artificial disc on top. I was very shocked when i heard I needed fusion.
    I did have another shot coming up on oct. 31. It was a facet injection ( Bilateral ) on L5. As soon as I got up , I felt a tremendous difference. Pain was gone. I was back to work the next day. Sad to say it didn’t last. Today is Dec. 21 I scheduled a second and third opinion. Dr. Corenman kindly advise me to what you would do if you were to operate on me? I hope you would be my 4th opinion.
    Again Dr. Corenman, thank you.

    Donald Corenman, MD, DC
    Moderator
    Post count: 8455

    I am confused. What are your symptoms? Do you have mainly back pain in the center of your back, mainly right leg pain or some combination of both?

    By your MRI report, it appears you have a large right sided L5-S1 herniation compressing the right S1 (not L4) root. You also have degenerative disc and facet disease of the L4-5 and L5-S1 levels.

    If your pain in mainly right buttocks and leg pain, you most likely would be a candidate for a simple microdiscectomy only. If you have back pain greater than leg pain and you received great temporary relief from your facet blocks, you might be a candidate for facet rhizotomies. Fusion is only for chronic lower back pain that prevents most desired activities and whne conservative measures fail (see section “When to have Lower Back Surgery” on the website).

    Dr. Corenman

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