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#6980 In reply to: degenerative disc bulge L5/S1 |
Location And Quality of Pain:
Pain started from the coxes lower end of the back and radiate in leg and lower back. Quality of pain is like injury or swelling.Quality of Pain changes (increases) with activity and no skin color changes when touched.Percentage of Pain by Location:
Pain originates from lower back and radiates in left leg and back and pressed the nerve root. 80% back and 20% leg. Severe pain in posterior and in coxes.Intensity of Pain:
6-10-VAS- for 2 years. Lower back 5-6 and leg 2-4. Very severe pain like injury.Weakness:
Yes, muscles are weak due to pain and always cramp occur in muscles.
Onset and length of Time symptoms have been present:
Pain started 7 years ago and gradually increased. I cannot sit and cannot stand even for 2 minutes. I feel most pain while sitting and standing.
Activities:
Activity causes severe pain in lower back and hurts me sitting and standing and bending towards. I cannot walk more than 20 minutes. Not mild pain rather severe pain in activity.Pain intervals:
I never free from the pain in the day. Only feel relief lying in the bed straight. And I felt little bit better after physiotherapy only for one to two months but after that it came back to its original intensity.Activity and Occupational Restriction:
Pain has changed my life. Every activity has been ended. I am on bed for the last 6 months and I am bearing this pain for the last 7 years.Diagnose:
MRI Recent report 7 days ago is:
Degenerative Disc Bulge L5/S1 in the small posterior.
Liability:
No Liability of any corporation. A forceful impact occurred during plane landing. And after 3 years I joined gym. Then I got into this severe pain.Previous Consultation or Treatment:
Within 7 years I’ve had many treatments but all were useless. Recently, Dr. advised me physiotherapy and some simple painkillers. And suggests me that you need no surgery but even after all these experiences I couldn’t get rid of this severe pain at all. I am very much disappointed. So, I am sending you my full history.
Kindly, Dr.Corenman help me getting rid of this pain.
NOTE: My pain is like needles are hurting/knocking inside me.
My nickname is Anila.
My real name is Attiya.
Previous Profession: Flight Attendant.Dr. Corenman,
This topic post relates to entry # 2548 of 3 weeks ago, found under my prior question regarding “Discrepancies in MRI / Foraminal Stenosis”… In the last 3-4 paragraphs of that post, I mentioned an appointment with a 2nd surgeon, to whom I’d been referred for evaluation of severe foraminal stenosis bilaterally at L2/3. In reviewing that portion of my post, it’s not difficult to discern that surgeon #2 was less-than-empathetic, and displayed a demeanor and overall bedside manner bordering on verbally aggressive, arrogant, and condescending. A family member of mine, a retired nursing instructor and RN administrator, accompanied me on that visit, which seems now to be a very fortunate occurrence.
About a week ago, I requested that surgeon’s dictated clinical notes from my visit with him. The notes were faxed to me promptly, and I was shocked and angered at what I read. I’ve counted no fewer than 9 statements / observations by this surgeon that are either absolutely false, or simply did not occur during the visit. I’ve also made note of several “neurological tests” he noted as having conducted, yet these “tests” were either feigned, or were never performed on me. A few examples are:
1. “Pt has downward going toes on Babinski”: HE NEVER PERFORMED A BABINSKI TEST ON ME, BECAUSE HE NEVER ASKED THAT I REMOVE MY BOOTS & SOCKS.
2. “Pt has warm, well-perfused bilateral lower extremities: HE NEVER LOOKED AT MY LEGS, FELT MY LEGS, NOR DID HE REQUEST I REMOVE MY BLUE JEANS AND BOOTS AND PUT ON AN EXAM GOWN.
3. “Pt has a normal heel-to-toe reciprocal gait, although she walks with a cane for balance”: DR. CORENMAN, HE NEVER SAW ME WALK, NOR REQUESTED I WALK TO ASSESS MY GAIT. I WAS SITTING DOWN THE ENTIRE APPOINTMENT, AND THE CANE HE NOTICED WAS LEANED AGAINST THE WALL. HE NEVER INQUIRED AS TO WHETHER I USE IT FOR BALANCE, TO ALLEVIATE PAIN IN MY RIGHT LEG, OR TO ASSAULT PEOPLE.
4. “Sensation is grossly intact to light touch”: IN STAR WARS, I BELIEVE I SAW LUKE SKYWALKER ASSESS HOW SOMEONE RESPONDED TO TOUCH FROM ACROSS THE ROOM, BUT OTHERWISE, I DON’T THINK DOCTORS CAN YET DO THIS.
5. “Isolated motor examination of bilateral lower extremities reveal 5/5 EHL, gastrocsoleus complex, tibialis anterior, and knee extension”: THE ONLY ONE OF THESE HE ACTUALLY PERFORMED WAS THE KNEE EXTENSION. AGAIN, I WAS WEARING COWBOY BOOTS, SO MY BIG TOE WAS IN HIDING AT THE TIME. HE NEVER TESTED THE REST OF THESE.
6. “Pt has +1 patellar and +1 Achilles reflex that are symmetrical”: HE GRABBED HIS LITTLE RED HAMMER AND HIT THE SIDE OF MY COWBOY BOOT ONCE ON EACH LEG, THEN HIT THE BACK OF THE HEEL OF MY BOOT ONCE. DON’T MEDICAL STUDENTS GET AN “F” ON ‘REFLEX QUIZ DAY’ IF THEY PULL SOMETHING LIKE THIS DURING CLINICAL ROUNDS?
7. There are numerous other outright untruths in my actual notes from the visit, however the one that struck me as egregiously unethical was his notation that he, “Strongly recommended the patient wean herself off of all narcotics.” DR. CORENMAN, THIS COMMENT IS COMPLETELY FALSE. HE NEVER DISCUSSED MY PAIN MANAGEMENT MEDICATIONS WITH ME, NOR DID HE EVER ONCE ASK ME WHAT PHARMACOLOGICAL MODALITIES I WAS CURRENTLY EMPLOYING. MY FAMILY MEMBER IN THE ROOM CAN ALSO ATTEST TO THE FACT THAT HE NEVER MADE THIS STATEMENT.
MY QUESTION(s) TO YOU AS A PHYSICIAN / SURGEON, WHO IS BOUND BY THE MEDICAL PRACTICE ACT:
1. These numerous false statements and untruths regarding neurological exams are now in my permanent medical file. Should another physician review these in terms of my ongoing treatment plan, he or she could be easily mislead or be reading false findings altogether, correct? This is potentially putting me at risk.
2. Why would a surgeon behave in this manner? And, given he only completed his residency 2 years ago, what does a young surgeon gain from treating a patient in this manner? Why would he simply lie about performing basic neurological tests while investigating a back problem?
3. His notation “recommending the patient wean off of narcotic pain medications” clearly insinuates that the patient “doesn’t need these medications”, or is perhaps “exaggerating symptoms or malingering.” I was stunned when I saw that notation in his visit report. Given my 30-year history of complicated spinal surgeries and degenerative joint disease, and my well-documented, fastidiously recorded pain management regimine, I consider such a comment libelous and harmful to my status as a responsible, legitimate patient.
What are my options regarding an amendment of these visit notes? Do i have legal recourse? And, I’m currently drafting a letter of complaint, to be addressed to the Chief of Orthopedics, as well as the State Medical Board. This surgeon is also affiliated with the medical school there. As such, he’s listed as an assistant professor of orthopedics. I highly doubt he instructs his medical students on their clinical rounds that reflexes should be tested while patients are wearing full body armor and big boots. Or, that it’s permissible to just falsely indicate on a patient’s chart that reflexes were checked, when they really weren’t.
This is my LIFE he’s toying around with, and his flippant assessment of my condition has me angered beyond belief. His actions clearly tell me he didn’t care, and he presumed I wouldn’t take notice of his incorrect techniques, or his outright lack of interest in investigating my symptoms further after a questionable MRI image.
Your thoughts on this matter?
The lean just due to the biomechanics does not make sense to me. There is something missing. The pelvis can accommodate a significant lean (increased lumbar lordosis) by anterior rotation. My understanding is that there is no pain in leaning forward but this position requires significant energy expenditure and when you “relax”, you are pulled backwards. This position is painful.
Even if the L5-S1 disc space is fixed in extension, this by itself would not cause the backwards bend as the pelvis and discs above could accommodate.
You might have some muscle contractures that cause this positioning. You need a thorough physical examination to determine the cause of this disorder.
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.You have a recently diagnosed L5 spondylolysis. Is there a slip of L5 on S1? This may not be identified on an MRI (you are lying down when the test is performed) but should be identified on standing X-rays, especially with flexion and extension views.
More likely than not, this spondylolysis was present for years before the aggravating work comp event and this lift of the patient was in just the right angle, force and direction to tear the pannus (see description of “spondylolisthesis” and “pars fractures” on the website for pannus description).
The treatment hope is that the tear of the pannus (the scar tissue that holds this fracture together) can re-heal and you can become pain free again. If the pannus tear is causing the pain, healing of this tear in my experience takes about 8 to 12 weeks.
A back brace is helpful but should only be used for lifting and heavy activities.
You do have degenerative tears of the discs at L3-4 and L4-5 and the significance of these is unknown.
In Colorado, going back to work full time does not mean the case is closed unless the treating doctor closes the case. How else to test the patient but by going back to work full time to determine if the patient can tolerate the stress of work?
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.My images can be found at https://docs.google.com/present
To answer your specific questions:1. My standing lateral X-ray indicates decreased disk height at L5-S1 and significant osteophye growth. T11-T12 and T12-L1 have Schmorl’s nodes and reduced disk height.
2. The specific angles have not been calculated, but you should know that the pain actually occurs after the extension posturing occurs (not before). My body isn’t reaching the extension posturing due to pain, but it is created after extension. As I try to straighten, my body is forced back to extension and more pain.
3. Flexion/extension xrays are included in the link.
4. I do not have a scoliogram X-Ray, but I do not have any signficiant scoliosis.
What I do want to provide you is the actual MRI report and CT Scan report text:
MRI:
FINDINGS:
There is no abnormal signal evident to suggest fracture. The pars interarticular are intact.T12/L1:Small anterior disc bulge is evident with disc space narrowing and disc desiccation. There is no central canal stenosis or neuroforaminal narrowing.
L1/2: There is no disc bulge or protrusion. There is no central canal stenosis or neuroforaminal narrowing. The facet joints are preserved.
L2/3: There is no disc bulge or protrusion. There is no central canal stenosis or neuroforaminal narrowing. The facet joints are preserved.
L3/4:Disc desiccation is evident with high signal in the 6 o’clock position of the annulus reflecting an annular tear. Small superimposed disc protrusion with minimal inferior extrusion is evident that deforms the ventral thecal sac without central canal stenosis. There is no neuroforaminal narrowing. Minimal left facet arthropathy is evident.
L4/5: Disc desiccation is evident with diffuse disc bulge symmetric to the left extending into the left neuroforamen. The disc bulge causes flattening of the thecal sac without central canal stenosis. Mild bilateral facet arthropathy is evident. All this causes bilateral neuroforaminal narrowing, mild on the left and minimal on the right.
LS/S1:Diffuse disc bulge is evident asymmetric to the left extending into the left neuroforamen. Small superimposed central disc protrusion is evident. Bilateral facet arthropathy is identified. Prominent disc space narrowing with endplate Modic change is noted. Endplate osteophytes are appreciated. The disc bulge, endplate osteophytes and facet arthropathy cause bilateral neuroforaminal narrowing, moderate to severe on the left and moderate on the right. The disc bulge and endplate osteophytes contact the exiting/exited nerve roots.
The paraspinal soft tissues are grossly unremarkable.
IMPRESSION:
1. T12/L1: Small anterior disc bulge
2. T12/L1, L1/2, L2/3 and L3/4: No central canal stenosis. No neuroforamlnal narrowing.
3. L3/4; Disc protrusion. Minimal Inferior disc extrusion. Annular tear.
4. L4/5; Disc bulge asymmetric to left Into left neuroforamen. No central canal stenosis. Bilateral neuroforaminal narrowing, mild on the left and minimal on the right.
5. L5/S1: Diffuse disc bulge asymmetric to left into left neuroforamen. Central disc protrusion. Bilateral neuroforaminal narrowing, moderate to severe on the left and moderate on the right. Contact exiting/exited bilateral L5 nerve roots.
CT SCAN:
-There is minimal retrolistliesis of L5 on Sl.
-The vertebral bodies are normal in height.
-Schmorl’s nodes are seen at Tll and Tl2 levels.
-There is reduction in disc space at T11-TI2, Tl2-L1 and L5-S1 levels.
-There is contiguous endplate irregularity with vacuum phenomenon in the disk at L5-S1 level.
-T11-T12, T12-L1, L1-L2,and L2-L3 levels: Mild bilateral facet hypertrophy is seen. There is also mild bilateral neural foraminal narrowing at T11-T12 level.
-L3-L4 level: There is a disc bulge with a bilateral facet hypertrophy and mild canal stenosis.
-L4-L5 level: There is a disc bulge with a bilateral facet hypertrophy causing mild canal stenosis and mild narrowing of bilateral central foramen.
-Pre and paravertebral soft tissue is normal.
-Spina bifida is seen at S1 level.
-There is evidence of sclerotic lesion likely a bony island.
IMPRESSION:
-Multilevel degenerative changes seen in the lower thoracic and lumbar spine, as described above.#6953 In reply to: L4-L5 Herniated Disk |Dear Dr. Corenman,
Thank you for your reply, to answer your questions, the symptoms are the same with intensification, I was able to manage the pain for all those years with being on Fentanul 100mcg/hr and Gabapentin 600mg (3+ daily) but in the last 2-3 months, they have worsen to the point that driving for 30 min is so painful that without cruse control I would not be able to drive to work and back.
My work consist of siting down at a computer (Security Analyst job) which I have had to leave or not be able to do full days work lately.
The pain is in the lower back, buttocks and right leg, numbness, burning and sharp pain like something would be between the disk pressing with a feeling like pressure. Lately I’ve also been feeling tingling in my private area like if I’m close to ejaculation without be erected and that really worries me, does this mean that a nerve could affected?
I am seeing my Dr. tomorrow so that he can put me on short term disability in order to not put my job in jeopardy due to not being able to keep my concentration and performing as I should. I will also request a new MRI to be done for comparison to the 2009 one which I have a copy of.
You have no idea how good it feel to get a reply from someone who understands this medical issue and nice to get some feed back. I’d like to thank you for your time and feedback knowing how busy you must be.
Kind regards,
Pierre -
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