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#7078 In reply to: abdominal surgery supine position with back issues |
Generally, the problem with your particular back disorder is worsened by extension (bending backwards). The normal position for an abdominal surgery is lying supine (on your back) with a pillow under your knees. Simply ask the surgeon to place two pillows under your knees and that position should protect you.
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.#7058 In reply to: Symptoms & Diagnostics: Sacroiliac Joint Dysfunction |Dr. Corenman,
Thank you so much for replying.
My longtime attending neurosurgeon contacted me Friday… He’s performed, or assisted on, 5 of the 9 surgeries on my cervical and lumbar spine. I admire him both as a friend (our patient / physician relationship spans 24 years), and as a surgeon and symptomatic detective. He travels around the country attending seminars, conferences, and groundbreaking surgical techniques, and has developed an interest in the SI Joint as a tandem suspect in neurogenic pain. Plus, I’ve likely put both of his daughters through school with my medical bills.
He’s seeing me personally this week, then while I’m there in town (he’s 3 hrs away), he’ll schedule me for the joint injection and any other diagnostics. As with any good surgeon and clinician, he’s not ruling my lumbar spine out, and remains open to other etiologies of pain whose symptoms mimic SIJD.
Should my physical exam in his office (imagine that… a real physical exam, complete with physical contact with the patient, a gown, and no cowboy boots) confirm SIJD, he will then refer me to an orthopedic colleague of his who has performed the iFuse procedure numerous times, with good results. Surgery may, or may not be, an option for me, however with my spine fused to S/1, the impossibility of PT that involves lower spine and sacroiliac adjustment, and with my history of poor results from injections, this might be the only thing that improves my current QOL and pain levels. Plus, I teach college, and miss being in the classroom… So, I want, and need, to get back to work. Another point of admiration for this guy… Should the orthopedist recommend the iFuse procedure, my neurosurgeon plans to attend and observe the procedure in the OR. He’s attended numerous seminars and surgical conferences on the procedure, but has never observed one. So, I think it’s cool that he’s using this opportunity to continue learning in his field.
QUESTION REGARDING SYMPTOM:
The radiating pain I’m experiencing, again, is across the area 2 inches above the gluteal cleft (I still like ‘butt crack’), runs bilaterally out to the top of the hips, then down the anterior thigh. My specific question is about the type of pain this is… Usually, it’s a horrible spasmodic stabbing pain, especially first thing in the morning. I am literally unable to roll myself over, sit up, or stand without help. I have to get out of bed using the infamous “roll and stand in one swift motion like a log” thing. Throughout the day, however, I’ll experience completely unpredictable “jolts” of pain, best described as an electrical shock, that, 1) originates at the area between the edge of the sacrum and the top of the hip where nurses give you injections sometimes; then, 2) shoots along a VERY distinct route along that seam of the SI Joint; then finally, 3) travels along a route down the side of my hip and down the anterior thigh. This “jolt” follows the same path every single time. It occurs when I’m standing, or as I’m sitting in my recliner. If I attempt to relax my entire low back, and attempt to “un-tense” myself, this happens. It will literally cause me to jump, almost like being hit with a taser gun. My friends find it amusing, especially after several cocktails. I find it a literal pain in the ***. Plus, it hurts beyond description.
Also, if I’m asked to lie on a completely flat, in-cushioned surface or exam table, I’m completely unable to do so. Upon lying supine and relaxing my back, I immediately experience a 10/10 spasmodic, stabbing pain in the areas of my sacrum and hips. It’s almost as if my hips don’t rest on the table with equal distribution (like one is slightly off the table or something). I’m suspecting this may be due to abnormal rotation or subluxation of the SI Joint. And, it sounds correlated with the replicated pain described in journal articles whose topic focuses on PT biomechanical exams. Your thoughts?
Any further thought as to whether these “jolts”, and positional anomalies, sound affiliated with the SI Joint, or does it sound associated with nerve root compression or facet pain *below* L4? My obvious concern is that on my MRI, the areas below L4 were, “largely unreadable and obscured by titanium artifact.” If the area below L4 was obscured, then a surgeon would be unable to assess whether all of these issues are originating there, rather than the SI Joint. In my opinion, the surgeon who ordered my MRI, and the second surgeon who said he couldn’t see anything due to artifact, should’ve considered ordering another diagnostic test that would better illuminate those lower levels instead of writing me off and not taking this case seriously. I’m not a doctor (well, medical anyway), but I think surgeons and providers have a professional and ethical obligation to investigate a patient’s symptoms if an initial diagnostic exam is inconclusive or otherwise rendered illegible. Am I missing something here?
Thanks again, and I look forward to hearing from you. In early August, we took a cross-country trip out west, and drove right through your area via I-70 West. What a beautiful region in which to live, and practice. You’re lucky.
S.W., NC
#7039Topic: Symptoms & Diagnostics: Sacroiliac Joint Dysfunction in forum GENERAL |Dr. Corenman,
During the past few weeks, both a primary surgeon and my PM team are beginning to strongly suspect that the severe pain (9/10 and 10/10) and very specific symptoms in my low back are due to Sacroiliac Joint Dysfunction. I appreciate your most recent reply, indicating that SIJD should be cautiously suspected in light of other vertebral or disk-related conditions. I’ve spent a good portion of the past 2 weeks reading orthopedic journal articles, case studies, neurosurgery articles, and other reliable literature whose focus is on the etiology, presentation, and treatment of SIJD. I’ve also viewed any number of medical conference presentation videos on this condition, and have learned a great deal about this emerging area of orthopedic focus. We’re not omitting my significant spine disease and surgical history as a potential suspect, yet all three of my attending specialists are growing increasingly more confident that SIJD is the primary suspect right now. I’ve found your replies to past questions really helpful, and hope you have time for a few more.
The extant literature, most of which is fairly recent, indicates that patients with histories of multi-level fusions are much more likely to develop SIJD within 5 years of their last lumbar fusion. Those whose surgeries involved iliac crest bone harvest are at even higher risk. Other correlates include patients with leg shortening unilaterally, those with premature development of DDD (< 35 years old), patients near 50 years of age, and women. QUESTIONS: 1. In your own chiropractic and surgical experience, do these correlates match those that you’ve personally seen in patients? I am a 48-yr-old female with an extensive history of DDD, onset at 18 years old. I’ve also had 5 lumbar surgeries, two of which were multi-level instrumentation fusions. The first fusion, in 1991, was augmented with autologous harvested iliac crest bone. 2. From the available research, I understand that most cases of SIJD are unilateral, although bilateral cases do happen in patients with advanced stages. The pain is severe, and originates lower than that associated with traditional lumbar discogenic, facet, or stenotic conditions. But, since the pain is so close to that of LBP, physicians oftentimes mistakenly overlook it. My doctors are fairly sure this is what happened with me… I presented with severe (9/10) pain, radiating across the sacral region to the pelvic crest, then downward to the groin and anterior thigh. I could not take what you’d consider a normal-length stride, and I described my pain to one surgeon as, “feeling as though my sacrum and hips were broken.” Due to titanium artifact on my MRI, it was simple for him to dismiss me with FBSS, saying my symptoms, “didn’t match anything on my MRI.” The research also indicates that surgeons should listen for a patient’s anecdotal symptoms as well as those considered more “important.” For example, clinical studies point to symptoms such as a patient’s inability to roll over or even move upon waking in the morning, and having extreme difficulty walking or standing without support. Other symptoms include poor sleep, waking with severe pain during the night, and an intolerance for positional variations such as Graeslen’s maneuver, distraction tests, and lying prone. If I attempt any of these positions, I am *literally* unable to move, feeling as though my low back and pelvis are broken and in severe spasms. If on my back supine, I am forced to roll like a log to my side, bring my knees to waist height, grab a shelf or significant other or tabletop or dog, and slowly bring myself upright again. If no one is here, then the entertainment value increases exponentially. In your extensive experience, would my symptoms piqué your suspicions for SIJD, in light of an MRI whose results are still debatable, and in light of normal AP/LAT/FLEX/EXT films? My pain is replicated upon all 5 biomechanical tests typically conducted to rule in SIJD. So… #3. If you had a patient whose pain was replicated on these maneuvers, and you felt an SI Joint anesthetic injection were warranted for a definitive diagnosis, how would you carry out the procedure on a patient who could not tolerate the prone position? Can patients be sedated for SI Joint injections? Even a pillow under my abdomen doesn’t help. #4. Once SIJD is diagnosed, what is the treatment for a patient with extensive instrumentation from L3/S1, and with the advanced symptoms I’ve described? Would any mode of PT be advised? Are iFusion procedures helpful in improving QOL and pain to manageable levels? What is a patient’s ROM like once fully recuperated from an SI Joint fusion? That’s all I want right now. To be comfortable, and to ride my Harley or walk my dogs. Apologies for the length of the post. I’m just trying to do as much research as possible until my next appointment. S.W., NC
#7038Topic: I've done L5 S1 Microdescectomy.. need help. in forum BACK PAIN |Good Day Doctor,
I’m writing to you and forgive me if i don’t sequence my things properly..
My name is Saleh.
192 cm, 108 Kg 32 yrs old. Handball Player.
2nd week of March 2012:
• I was feeling very minor pain in the Right lower back .. during training , i jumped using my R Foot and felt like knife cutting my internal thigh severe muscle strain .. but NO back pain at all whether moving or bending.
• I put ice on injured thigh…..and next day along with the thigh pain I felt kind hardness in my R calf muscle with burn sensation in it, as well as back thigh / right hip. I was limping for 3 weeks..
• Kept using relaxon/ voltec for pain relief a bit..
2nd week of April 2012:
I made MRI and the findings was:
Technique: Multiplanar image acquisition was performed using various pulse sequences
– Spinal curature is maintained.
– Vertebral bodies show normal bone Marrow signal.
– The intervertebral discs at d11-d12, l4-5 and l5s1 showed loss of normal bright.
– T2w signal with partial reduction of disk height consistent with degeneration.
– Evident l4-5 disc bulge compromising the ventral aspect of the thecal sac with evident bilateral neural foraminal compromise.
– Area of abnormal signal related to Right antrolateral aspects of the thecal sac opposite L5-S1 disc extending cranially and caudally measuring roughly 2.8 x 1.4 cm in maximum craniocaudal and transverse diameters likely extruded discogenic material its seen compressing the right aspects of thecal sac, obliterating right lateral recess compressing preforminal nerve roots.
– The spinal canal diameter appear within normal limits.
– Vertebral appendages and facet articulation are normal
– No abnormal pre or paravertebral soft tissue signal seen.
Impression:
– Degenerative disc disease L4-5 disc bulge.
– Possibility of L5 S1 disc extrusion with migration of discogenic substance as described correlation with contrast study is advisable. (DONE the contrast)
I was diagnosed with L5 S1 disc prulaps and went through microdiscectomy surgery End of May 2012.
CURRENTLY:
• severe pain improved after surgery but STILL There is NO PROGRESS weakness associated with R calf muscle pain
• I feel that weakness due to muscle weakness but along with burn sensation i believe its due to neuropthic affect with pinched nerve as shown in MRI..
• I feel tolerable pain during activities except during walking or jogging weakness in leg goes up.
• Now feeling stable burn sensation and pulsation in top of heal, calf, back thigh. But very tolerable.
• I can do my activity normally except try to speed up walk or jog ..
• No skin color change.• the percentage of related pain in the back, buttock (66%) and leg 40% but leg weakness what is most bother me..
Intensity of Pain
Lower back 2/10
Leg Buttocks 5/10
• I didn’t notice any kind of improvement except the interior thigh pain..
• Walking or jogging is pressurizing my calf muscle and i feel it goes weaker.
• sitting that increases the burn sensation
• I don’t feel much comfortable when sitting more than 15 mins and i’ve to adjust myself.
• I can walk for an hour But with very regular speed.
• Sitting longer increase the burn sensation.
• Driving and computer work increase the burn sensation and it goes back and forth from buttocks back thigh, calf muscle down to heal.
• No REAL back pain.
• I can do everything including cross trainer, except jogging / running more than 10 meters, then the weakness starts.
• Computer work is my daily activity. I rest for few mins every time i feel the burn sensation by doing quick stretching….Looking forward for your advice..
Respectfully,
Saleh
#7029 In reply to: Ice or alternating Ice/heat? |Based upon your description of your MRI, it sounds like you have a degenerative spondylolisthesis of the L4-5 level. “Minimal grade 1 anterolisthesis of L4 on L5. Pars interarticularis defects are not demonstrated, but there is facet arthropathy and ligamentum flavum hyperthrophy and fluid in the facet joints at this level. There is mild edematous change in the pars margin at the L4 level, but no spondylitic break is noted. No bulged disk or disk herniation”.
You have no pain when you sit, no lower back pain with any activity and “severe sciatica” when you stand and especially hike. This condition sounds to be classic stenosis, either foraminal or central (see website). Biking causes flexion which opens the spinal canal. Hiking down from Booth Falls causes extension (center of gravity is shifted backwards) which narrows the spinal canal and typically aggravates this condition.
Pain and swelling respond better to ice. Muscular tightness and spasm responds better to heat. Be careful with both as I have patients in my practice who have burned their skin using both methods.
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.#7026Topic: Ice or alternating Ice/heat? in forum BACK PAIN |Dear Dr. Corenman,
This all started after a 3,000 feet ascend hike up to Booth Lake in Vail end of July…. Gorgeous hike, but it hasn’t been good for my spine! 4 weeks ago the pain intensified into severe sciatica like pain all the way down in the left leg, when I stand still or walk. No pain if I sit. I have no back pain, neither sitting or standing. Started PT last week (incl. dry needling: gluteus muscles, QL and lower back muscles were all very tight). I obviously stopped running & hiking for the past 4 weeks and the past 10 days I also stopped walking and I try not to stand.
Just got the MRI back:
“Minimal grade 1 anterolisthesis of L4 on L5. Pars interarticularis defects are not demonstrated, but there is facet arthropathy and ligamentum flavum hyperthrophy and fluid in the facet joints at this level. There is mild edematous change in the pars margin at the L4 level, but no spondylitic break is noted.” No bulged disk or disk herniation.From PT I got core exercises, exercises as used for spinal stenosis and 2×10 min daily cardio on a stationary bike. That all feels very (!) good. I’m planning on continuing that. I also take 2 Aleeve in the morning and use a pillow at night lying sideways.
My question is: do you think I should ice the L4/L5 location for 20 minutes several times per day? Or alternating ice and then a hot bath for my tight muscles? Then ice again on L4/L5? I must have inflammation going on, but I also have very tight muscles. There are many opinions about ice and heat, but I would really value your opinion! Thank you for your time. Hopefully I will be back to hike in Vail. From Littleton, CO
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