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#8679Topic: Mri reading with motor weakness in arm in forum READING X-RAY, MRI & CT SCAN |
First let me say thank you to all of the great information on your forum.
I am an active athlete and do a lot of pitching and recently was diagnosed with a herniated disk at c5-6 level. The report states the following:
There is herniation of the disc posteriorly on the right with extrusion of a relatively large disk fragment. The extruded fragment effaces the dural sac and results in some cord flattening on the right. There is severe effacement of the C6 root sleeve. The left NeuralForeman is widely patent.
Vertebral body height, alignment, and inner spacing appear otherwise within normal limits. No significant marrow abnormality is noted. The cervical spine cord is of uniform signal intensity.
My arm feels like it has no explosiveness or fast twitch muscle fiber use. I do not have any pain that’s really significant mostly just the arm weakness. I have been seeing a PT which has me doing extension exercises and seems to think I’m getting stronger. I also seem to feel that way but my concern is, is this a realistic approach to get back to 100%? I’m worried that the longer I wait the higher the chance of it never coming back. This has been going on for about 2 months.
I am still throwing thinking that if it does start coming back that my arm will be in better condition. Based on the findings what do you believe would be my best option? I am 39 but in good shape.
Thank you for your help and any advice,
Ryan
#8666Topic: L5-S1 sequestration: prognosis and treatment? in forum BACK PAIN |Greetings, Dr. Corenman! I’m writing on behalf of a good friend of mine, who is currently in hospital in Saint–Petersburg, Russia, due to disturbing back and left leg pain. He was hospitalized two weeks ago when the pain became intolerable. My friend is a 29 y/o male. He works as an engineer and spends a lot of time in front of the PC. Nevertheless he does exercises, walks a lot and rides a bike. He had a long history (~15 years) of lower back problems, with pain occurring sometime every year. In January 2013 the back started aching again and he did an MRI scan, here are the findings (I’ve translated them from Russian up to my knowledge and understanding) (picture here, I cannot properly attach the link, but you can copy and paste it into the browser):
imageshack.us/a/img24/7097/mityamri0801132.jpgOn the series of lumbar T1 and T2 weighted MR-images lordosis is normal. L5 vertebral body is posteriorly displaced by 0.8 cm. On T2 disc height and signal intensity of L4-S1 discs is lowered.
Dorsal medial L4-L5 disc bulge up to 0.6 cm, pressing on the epidural space and spreading into the adjacent foramina.
Dorsal diffuse L5-S1 disc bulge up to 1.1 cm, pressing on the wall of dural sac and spreading into the adjacent foramina, more on the left, and caudally along the S1 body up to 1.1 cm. Anteposterior width of the spinal canal is narrowed to 0.9 cm.
Dorsal Th12-L1 disc protrusion up to 0.3 cm, pressing on the anterior epidural space. Spinal canal width is lowered at the levels of disc herniations, Spinal canal signal on T1 and T2 is normal. Minor Schmorl’s nodules of Th12–L5 vertebrae. Vertebrae are normal in shape and size, signs of degeneration in vertebral bodies.
Impression: Signs of degenerative changes of the lumbar spine. Herniation of discs L4-L5, L5-S1(with caudal spread). L5 body retrospondylolisthesis.The pain resolved without intervention, however one day in March all of a sudden the back pain returned and he lost feeling of his legs. He was given an injection by the ambulance team and prescribed some medicine. After a few days he could walk again, returned to work and even went to the swimming pool once, but then came the radicular pain in the left leg and partial numbness of the foot. He stayed at home for some time but the pain persisted and he decided to go to the hospital on April 26. Another MRI scan was made on May 3, here are the pictures and the findings (again translated from Russian):
imageshack.us/a/img809/9196/mityamri1030513.jpg
imageshack.us/a/img153/1258/mityamri2030513.jpgOn this lumbar T1 and T2 weighted MRI lordosis is normal.
Degenerative changes of intervertebral discs are observed: Th12-S1 level demonstrates lower signal intensity and disc height, L4–S1 levels show lower disc height.
Th12-S1 level shows right posterior paramedian disc bulge with a sagittal dimension of 3mm, pressing on the anterior wall of dural sac. Right foramen is moderately narrowed. Anteposterior width of spinal canal is 19 mm.
L3–L4 level shows dorsal disc bulge of 3 mm.
L4–L5 level shows posterior medial disc bulge, with a sagittal dimension of 4-4,5mm, pressing on the anterior wall of dural sac. Foramina are moderately narrowed. At this level anteposterior width of spinal canal is 16 mm.
L5–S1 level shows left posterior paramedian sequestered disc herniation with signs of caudal migration to lower 1/3 part of S1 vertebra, with a sagittal dimension of 12 mm and vertical size up to 15 mm, pressing on the anterior wall of dural sac and left S1 root. Anteposterior width of spinal canal is 11 mm.
Degenerative changes are observed in intervertebral joints as thickening and surface roughness of articular facets. Schmorl’s nodules of Th12–L5 vertebrae. Adipose degeneration and osteophyte growth on vertebral bodies. Paravertebral soft tissues normal.Impression: Degenerative changes of lumbar vertebrae. L5–S1 left posterior paramedian sequestered disc herniation. L4–L5 posterior medial disc protrusion. Th12-S1 paramedian disc protrusion. Signs of spondyloarthrosis, spondylosis.
He was put on conservative therapy (laser therapy, magnetic therapy, some percutaneous injections), but there’s been no improvement since he had been hospitalized two and a half weeks ago, radicualr left leg pain and numbness in the foot are still there. He can barely walk more than 10 meters without rest, and the pain now interferes with his sleep.
A senior surgeon at the hospital said that a surgery is necessary, an endoscopic microdiscectomy in this case. Two other independent doctors (though not surgeons) gave similar views.I’d like to ask your opinion: do the diagnosis and the choice of treatment look correct? Here in Russia medical services are sometimes a serious gamble, it’s hard to find a decent doctor.
Best regards,
Yegor#8661 In reply to: c2 and c3 please |If your surgeon thinks that you have instability and this jeopardizes your spinal cord, most likely you do need an operation. A fusion will stabilize the unstable levels. Let us know what the MRI and flexion/extension X-rays note.
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.#8642 In reply to: pars defect – stress fractures |If your son has pars fractures at L3 and the MRI or bone scan does not indicate any attempt at healing, these fractures will have little chance of healing even with rest and bracing. If the L3-4 disc is still normal appearing on MRI and there is no slip on flexion/extension X-rays, you could consider pars repairs. If there is degenerative disc disease present at L3-4, there is a slip of L3 on L4 or the gap between fracture fragments is large (greater than 3mm), pars repair will not work and fusion will have to be considered.
If fusion is considered, a work-up may need to be undertaken to see if the L3-4 level is the only pain generation level due to the degenerative changes below this level.
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.#8634 In reply to: L5-S1 annular tear, 4 months of pain and frustration |Pain can be generated by the disc, facet or nerve. The slip at “only” 5% is still a slip with the fact that global failure of this segment (disc and facets) has to occur. This is much different than an annular tear by itself.
In any slip (or any patient with pain for that matter), standing X-rays with flexion/extension views needs to be included. These are the only tests that dynamically can determine what the mechanical status of the segments are.
The MRI can demonstrate the pars fractures associated with an isthmic spondylolysthesis but the images have to be high quality and the radiologist has to look for these fractures as they are subtle to identify. The X-ray sometimes is a better tool to identify these fractures.
Normally, if an epidural was ineffective, i will not order a second. There are rare times a second can be effective but that percentage is not high.
I am a fan of discograms in the correct settings. I use the discogram as a preoperative test however. If you are not contemplating surgery, I would not have a discogram.
PRP in my opinion is not generally effective for disc pain or instability and has no place in the spinal canal.
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.#8621 In reply to: L5-S1 annular tear, 4 months of pain and frustration |You have performed an excellent job in recording your history. This really gives me most of the information needed to lend some advice.
Your problem is more than just an annular tear. You have a degenerative spondylolisthesis of L5-S1 which means this is a global breakdown of the stabilizing structures at this level. The facets are the bony structures that prevent forward slip of one vertebra on the other. These facets have to fail in order to allow the vertebra to slip forward (as is the case with a degenerative spondylolisthesis). With the failure of the facets, the disc is subjected to sheer forces that eventually produce the annular tear (discs do not tolerate sheer forces well).
This global failure then allows one vertebra to slip on the other. Three symptoms can occur. Lower back pain is one typical symptom where any loading of the spine puts undue pressure on this segment and causes stretch of structures that are imbued with pain nerves (nociceptors).
The second symptom is instability. This is the apprehensive feeling that if you put your back in a certain position, the back will “give way”. An unexpected force on the back (unexpectedly stepping off a curb that is deeper than expected) will cause a severe pain in the back that will almost drop you to your knees.
The third symptom is nerve pain that radiates down the legs with standing and disappears with sitting, leaning forward or lying down. This occurs due to the compression of nerve roots with extension (bending backwards-necessary for standing and walking).
Just to be sure, the most common slip at the L5-S1 level is an isthmic spondylolisthesis (see website) so make sure this condition is ruled out and the problem really is a degenerative spondylolisthesis. The treatments do differ.
The best treatments for this disorder are a core strengthening program with neutral spine precautions and epidural steroid injections to calm down the nociceptors. If you fail all conservative treatments, this disorder responds very well to 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. -
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