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Given the band of severe bilateral pain approximately 2″ above the gluteal cleft (seriously, I just really like “butt crack” better, but…..), the intense and sudden “bee sting” sensations in the upper buttocks and hips, and the bilateral throbbing in the anterior thighs and lateral calves, could spondylolithesis at L2/3 be a possibility? Or, could hypertrophy of the facets, in and of themselves, be a pain generator? I have several that appear thickened and markedly inconsistent with others. Unfortunately, clarity of the areas below L4 is severely compromised due to titanium artifact, however those around L4 and below seem to jut out to the left (if you look at the sagittal view), then encroach upon the area where you can see the cauda equina. Is it typical for these bony structures/facets to significantly jut out like this? Or, are they supposed to be somewhat aligned with the far right edge/border of the spinal canal?

My PM anesthesiologist ordered plain films of my lumbar spine today, making sure to include both flexion and extension views. The dynamic stabilization instrumentation, because of that small hydraulic “hinge”, makes flexion much easier than extension…bending backward is almost impossible. Which is more important in assessing instability and spondylolithesis?

As always, thank you again.

S.W., NC

Dr. Corenman,

Your review and reply this morning is really appreciated; it’s unfortunate that patients like myself, whose pain and other symptoms are obviously originating from somewhere, are forced to investigate and research their conditions themselves. In a matter of six weeks, I’ve had two surgeons all but shrug off my symptoms, sending me out the door with vague or otherwise nebulous “diagnoses” simply because they lack the initiative to investigate just a little bit deeper in order to find the etiology of the pain. Because I’ve undergone 9 spine surgeries, and have an extensive amount of post-operative scarring and arthritis, I’m now presumed to be beyond the short amount of time it would take a curious or inquisitive surgeon to investigate additional possibilities for my symptoms. I fully understand that there comes a time when operative or invasive procedures would be futile or otherwise detrimental to the patient… I’m a realist, and completely comprehend the notion that surgery isn’t always a “cure all” for patients with complicated and extensive spinal histories. But, my symptoms are very specific, and both my pain management team (two excellent anesthesiologists) and my long-time neurosurgeon are in agreement that my symptoms are “classic presentations” of stenosis and/or instability at very localized levels in my lumbo-sacral spine.

Exactly as you suggested, my MRI yielded “nothing” in the opinion of “2nd opinion guy”, and severe stenosis in the opinions of two radiologists and my PM team. Since there is titanium artifact from L3 to S1, an absolute determination has yet to be established. It seems likely, however, that L2/3 is the suspect — my symptoms are a textbook presentation of compression at that level, and the sagittal views clearly show disk bulging there. The radiologist noted “diffuse disk bulge”, with “moderate to severe foraminal stenosis bilaterally.” And again, 2nd opinion guy all but insinuated that the radiologist was hallucinating and possibly possessed by little green men… It’s all maddening, but at the same time, comical.

As the patient, the one who’s living with acute pain and diminished quality of life, I think a logical gameplan is needed BEFORE I have the Medtronics neurostimulator implanted. On Monday, I plan to talk with my PM physician to request a few more plain X-rays of my lumbar spine that include views of the sacral and SI structures. As you recommended, I plan to request flexion and extension views. If pseudoarthrosis or spondylolithesis are present, those views would clearly identify them. I’m not sure if this is relevant, but one of the reasons my fusion extended to S-1 years ago was due to spondylolithesis at L5/S1. The orthopedic surgeon who performed that surgery (2008) tactfully warned me that I’d likely have problems at L2/3 in the future, given the increased load that level would have to endure.

Before I have a $30,000 device implanted, I think I’m being prudent in covering all the bases to determine what, exactly, is causing this. My PM physician would likely agree that perhaps a CT scan with contrast might help illuminate compression obscured by artifact in my MRI. Or, would a myelography be helpful in this situation? Finally, if L2/3 is found to be the origin of my symptoms, would a fusion extension to T11 or so be warranted, or could that level be repaired without fusing upward? Aside from flexion and extension plain films, can you lend an opinion as to whether any of the diagnostic procedures I’ve mentioned would help narrow this problem down?

I’m sure that during your career, you’ve encountered patients just like me — extensive spine issues, and a long history of surgeries — who just want an answer or somewhat definitive diagnosis. Whether surgery could help is almost secondary… In other words, just knowing WHAT it is, whether it can be fixed or not, makes it a little easier to live with and tolerate.

I look forward to hearing from you when you have time… Thanks again.

S.W., NC