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Dr. Corenman — thank you for providing this valuable service.

I’m an otherwise healthy 35 year old male who has been suffering on and off (mostly on) for the past 4+ months and the frustration and worry is really starting to get to me. I’ve decided to write up an extensive history of my pain using your guide as a template (I figure this will be useful for visits to specialists in the future).

My primary question right now, if you are able to address it, is: what is the likelihood that conservative treatment is going to result in full recovery? It seems like the annular tear in my L5-S1 is the source of my problems, and I have heard a wide range of belief on whether or not this is likely to heal on its own, and in what time period. Am thinking about visiting a spine surgeon in the near future for additional opinions, but would appreciate your perspective on my case.

Here’s my report:

LOCATION AND QUALITY OF PAIN

Primarily a constant, dull, tight, aching pain or soreness in the lower back, with periodic pain (dull, aching) in groin, buttocks, and both legs (have felt symptom further down the right leg all the way to the feet, no further than the thigh on the left leg). Sometimes leg pain appears suddenly but it’s hard to describe as “shooting.” 80%/20% pain distribution back vs legs, again the back is kind of the standard and the leg pain comes and goes.

Activity has been mostly limited of late, so it’s hard tos ay that activity drives it much. Standing or sitting for extended periods of time exacerbates the pain. Of late, I’d say that the sensation is almost that of fatigue — I am generally at a level of pain that, by itself, is not debilitating, but if I sit in a chair for an hour without moving, I start to feel a “pressure” and onset of fatigue. Lying down (typically with pillows under my knees) is generally my most functional position.

No skin sensitivity or change in tone. No ‘foot drop’ or loss of strength in legs. Can still walk short distances, perform most physical therapy exercises on most days, operate exercise bike, etc.

INTENSITY OF PAIN

At its worst, pain was around 7 on the VAS scale, for a period of about 10 days.

For the past 2 weeks, I’ve been holding relatively steady at a pain intensity of 3-5. Often the pain is worse in the late afternoon / evening, particularly if I’ve had an “active” day. (My level of activity is depressingly minimal, a ‘busy’ day might involve 30 minutes of stretching, sitting at my desk for a couple of hours, and running an errand or two in my car).

WEAKNESS

I don’t particularly feel weak performing individual activities, but I do feel a kind of general weakness at times, again, a feeling of fatigue, like standing or sitting puts an undue amount of ‘weight’ on my body and I feel tired much of the time. Generally am able to perform most activities, just not nearly as much as I would like.

ONSET AND LENGTH OF TIME SYMPTOMS HAVE BEEN PRESENT
ALSO: HISTORY OF CONSULTATIONS AND TREATMENT

12/30/2012 – pain started morning after flight home. After about a week of rest, pain went away completely and resumed active lifestyle for about 4 weeks.

2/3/2013 – pain returned after a day of high activity (moving furniture, dancing) but in low level form. a few days later, attempted to bike to a coffee shop and arrived in excruciating pain, unable to work, ended up needing to get a ride home from a friend.

started visits to a chiropractor for adjustment + rehab that week. improvement noticeable in the first week, then a sudden setback to high level pain (7/10). weeks of chiropractor visits had things moving in the right direction.

mid march, pain seemed mostly gone and i attempted to start biking again. had a moderate setback, stopped biking, haven’t been on a non-stationary bicycle since. went to san francisco for a conference in late march, was mostly pain free.

3/31 – flew back home, slept in my bed one night, and on April 1, pain returned. pain increased for the next 10 days culminating in worst pain of the experience (7+/10, completely incapable of working)

4/12 – decided to stop seeing my chiropractor (no more adjustments) but continue with the physical therapy. went to see my GP for the first time, he prescribed oral steroids (methylprednisolone). no effect one week later, GP referred me to a pain specialist.

4/19 – visited pain doctor, he ordered an MRI (full results below) and prescribed hydrocodone for pain management.

short verison of MRI results to my understanding: degenerative L5/S1, disc dessication with 25% loss of dorsal disc height, annular tear, grade 1 (5%) degenerative spondyliosthesis. pain specialist recommended an epidural steroid injection.

4/30 – ESI administered.

5/8 – 8 days later, no real improvement in symptom. frustrated.

ACTIVITIES

Prolonged sitting or standing increase pain. Sitting in aeron chair is generally more amenable for longer periods of time (interrupted periodically for ‘stand and reach’ stretches). I attempt to work at a standing desk periodically but have trouble doing so for more than 15 minutes or so.

Walking is usually pretty OK, and I can manage 15-30 minute walks with no-little extra pain. I’m not sure I would venture out for a longer than 30 minute walk at the moment.

Had a couple of setbacks after riding a bike in the city (which was a 5-10 hour/week activity previously) so I’ve stopped. I just installed a bike trainer in my house and am experimenting with biking in a controlled situation to get cardio exercise.

I tend to spend 8+ hours a day prone (in addition to 8 hours of sleep). I work from a prone position and can better concentrate and feel less distracted by the pain. I try to work sitting (2-3 hours a day) or standing (< 1 hour a day) which is mostly in front of a computer. Also had a couple of primary setbacks (including the initial symptom) the morning after a flight. PAIN INTERVALS Pain is pretty constant and doesn’t seem particularly exacerbated by any one motion or movement, rather it accumulates with daily stress. As described in my history, I’ve had periods of pain lasting between 1-4 weeks. The current episode is in its 6th week with no sign of abatement. ACTIVITY AND OCCUPATIONAL RESTRICTIONS The pain has been strongly disturbing my life along many key axes. I am incapable of focusing on work for more than 20-30 hours a week in a good week. Work meetings are frequently interrupted as I have to move or lie down to alleviate the pain. Social life is restricted, I can’t go out as much or be nearly as active with friends. I’ve had to abandon scheduled vacations, such as a recent planned camping trip. Dating seems like an impossibility right now. I do attempt to go out a few times a week but generally have to cut my activity short. Bicycling was my primary exercise and has been abandoned for the past 2 months, though I am attempting to reintegrate it as an exercise in a controlled environment (with a bicycle trainer). I do 15-60 minutes of physical therapy, core strength exercises, and so forth, on a daily basis, including working with a physical therapist for 2 hours a week. I run my own business (video game development) which is a blessing and a curse — I don’t have to take time off when I’m incapable of working, but I also have no disability options, and my business suffers if I am incapable of working. My work duties mostly involve operating a computer. I’ve missed a lot of hours this year as a result of this issue. MRI RESULTS (4/19/2013) Technique: High field strength multiplanar imaging of the lumbar spine without gadolinium. Findings: L5-S1 grade 1 degenerative spondyliosthesis. No fracture. No aggressive nor destructive marrow pathology. The conus terminates normally L1 with no abnormal signal of the lower thoracic spinal cord nor conus. No paraspinous soft tissue abnormality. L5-S1: Disc dessiccation with 25% loss of dorsal disc height. Increased T2 signal in the dorsal annulus, less than CSF intensity, age indeterminate likely old annluar tear. Disc protrusion associated with annular tear 2 by 11 mm AP by transverse diameter. Mild to moderate deformity of ventral thecal sac in conjunction with spondyliosthesis, approximate 5% degenerative spondyliosthesis. No mass effect on descending nerves. Mild left more than right facet arthorpathy with ligamentum flavum buckling on the left, 3-4mm. Mild to moderate left and mild right neural exit foraminal compromise, potential for irritation of exiting left more than likely right L5 nerve with weightbearing, more so there is instability. L5-L4/L4-L3/L3-L2/L2-L1 – Normal disc hydration, normal disc height, no disc hernia, no mass effect on descrending nerve roots, fat preserved around exiting nerve roots, no facet arthropathy detected.
Much obliged for your time and attention,
David

Dear dr. Corenman,

I am writing you from Italy, I am a 33-year-old gentleman. In September 2002 I had an “hit and run” accident during which I experienced the fracture of L1-L2, with loss of consciousness for about 15 minutes. When I became conscious again, I immediately started to feel a very severe pain between L6-S1 (I have 6 lumbar vertebrae), exactly at the center of the spine in mid location. This pain never stopped since then and has made my life a REAL hell.
The worst problem is that diagnostics could never explain this pain. Neither X-rays or magnetic resonance or CAT could find anything anomalous or able to justify the bad pain I continue to have. Despite this, pain never reduced in these last 11 years. I had several surgeries that didn’t meet expectations, some of them even worsened my previous condition.

SURGERIES THAT DIDN’T GIVE ANY RESULT: 2004-2005,“Denervation” of the “articular faces” of the spine (L5-L6-S1) with radio frequency. This surgery was repeated twice and didn’t cause any effect. In may 2011 I tried the “pacemaker against pain” but it doesn’t improve my condition, so it was removed.
In march 2013 I had a fusion of L6-S1, but the pain is still the same, located just under the fusion.

SURGERIES THAT WORSENED THE SITUATION: Positioning of a DIAM between L5-L6. This intervertebral shock absorber was placed about 9 years ago, with the aim of reducing the pressure on the lower part of the spine. In reality, it was not just unable to diminish the symptoms but pain moved down towards inferior limbs and the disk L5-L6 has undergone a continuous deterioration even reaching a contact with the spinal cord. In July 2010 the diam was removed, and the pain on my legs goes better.

SURGERIES THAT MODIFIED THE PAIN ZONE: In December 2009, “Denervation” of the interspinal ligament of L6-S1 with radiofrequency before and a following surgery of resection of the same interspinal ligament have brought some very small improvements. Also I had an ablation of L6-S1 spinal process. The pain has slightly moved down, both in intensity and in location, but still remaining at the center of the spine. With the denervation with radiofrequency it moved downwards of about 2 centimeters, still remaining between L6-S1 but now much closer to S1. With the following surgery, when the interspinal ligament was removed, pain has slided down in intensity as well as in localization.

Right now the pain continues to be very bad. I can stand upright only for a minute. Pain is not radiating, it is more like a stab. I have tried every kind of therapy, really everything. I had manies check, but receiving always the same answers, that is “diagnostics” is not showing anything special to justify this continuous pain and that I cannot do anything about this and I have to live like this. I must take drugs just to stay at home. I can’t go out because the pain is too much strong.
I am aware that you are used to hopeless situations but I am really desperate. The pain is just unbearable. I am not living … It is like being trapped inside my own body. It is a nightmare I have been living through since 11 years and I would like to wake up. Please, please help me, I am imploring you.

Regards

A.P.

Dear Dr Coreman,

Writing below my history as best as I can. I have had back pain after shovelling for 3 hours eight months ago. I also have lower foot discomfort in the bottom of the left foot. I developed simultaneous depression. The back pain eased a bit after 4 weeks but never cured. There have beenn varying symptoms since then. I persisted working for six months. CT and xray did not show anything. Ct was done because of non availability where I lived. During this whole six months it was agonising and I could not stand at the end of the day. I gave up work after this and have been bed ridden ever since. Had a recent MRI is showing broad disc protrusion at l5 s1 with moderate foraminal compression and left sided protrusion at l4 l5 with moderate foraminal compression. I am currently experiencing left sided muscle twitching and back pain. From the very begining the symptoms have been left sided. The back pain is more to the left side. It varies in intensity and nature, sometimes burns, sometimes aches. At times it is all thru the lower back and buttocks. Long standing is not possible. I am bed ridden these days and cannot take up a whole day. I also have left sided lower foot pain and sensations and muscle twitching.

As I am bed ridden and unmotivated I do not believe I can do more in terms of actively seeking treatment. However, I would like to know what would be the natural history of this condition if I let this condition go on without doing much ? I do not think I would explore surgical treatment as probably post op I would remain unmotivated and not do whatever is required to get going.