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There is a debate regarding the sacroiliac joint as a pain generator in spine surgery circles. I do believe this joint can cause pain but not to the extent that many others do. You do have a situation that the sacroiliac joint has more stress than normal (three level fusion to the sacrum) but your symptoms do not reflect sacroiliac pain.

Sacroiliac joint pain is local pain right over the joint itself that can radiate to the buttocks and rarely the posterior thigh. This is not your pain. The sacroiliac joint is incapable of generating “stenotic” type pain as there are no movable foramen or nerve exit holes that can change in diameter with motion.

“Butt crack” is a term we spine surgeons should use as it is perfectly descriptive but unfortunately we have to use “gluteal cleft” instead.

Pain that originates in the sacral region, radiates into the anterior thighs and down to the lateral mid-calf is in the referral area of the L2 through the L4 nerves. If you have a fusion from the sacrum to L3, there are two possibilities for pain referral. One is a pseudoarthrosis at L3-4 that is causing nerve compression. The other possibility is a breakdown of L2-3 with nerve compression from this level.

Your symptoms are classic for mechanical compression due to spine position which is very common. The MRI may not demonstrate significant compression but the standing flexion/extension x-rays may reveal this instability. Selective nerve root blocks should yield temporary relief (see SNRB and pain diary on the website for further information).

Dr. Corenman

Congratulations on your weight loss. That will be helpful in your overall recovery from this disorder.

Being 24 years of age and carrying a diagnosis of lumbar canal stenosis means you have congenital stenosis (your canal is small to begin with). The condition called neurogenic claudication can occur with canal narrowing. The symptoms are characterized by low-lower back pain (back of the pelvis pain) caused by prolonged standing and walking. Symptoms can radiate into the thighs the longer you stand or walk.

If your pain is lower back pain brought on by lifting and bending and feels better when you stand and walk, you probably do not have symptoms of neurogenic claudication but have symptoms of degenerative disc disease.

Each condition is treated differently. You want to encourage flexion activities with neurogenic claudication (cycling, skiing, modifying swimming with a snorkel) and encourage extension exercises with degenerative disc disease (swimming, gym workouts, swiss ball extension activity). Epidural injections can help in either case.

Dr. Corenman

Disc herniations in the thoracic spine are difficult to treat if epidurals are ineffective. The pain can originate from four potential generators: the nerve root compression, the degenerative disc itself, compression of the spinal cord or from a condition called Scheuermann’s.

Nerve compression should cause pain that radiates around the chest wall associated with numbness of that dermatome (the sensory area the nerve serves). This condition is unlikely to be the painful disorder as it is very uncommon.

The most common pain generator is disc degeneration itself. Discs act as shock absorbers. When discs become degenerative, they tear which can cause pain as the disc wall is full of pain nerves in some patients. Patients with this disorder have more pain with loading and vibration (unfortunately, airplane vibration compounds this problem).

Scheuermann’s disorder is associated with degenerative disc disease. In this disorder, which initially occurs when the patient is young, the endplates of the vertebra deform but the pain might not develop until later in life. This disorder which is more common than you think is recognized by the irregular endplates and wedging of the vertebral bodies.

Finally, herniations that cause cord compression are not typically severely painful (but can be). Symptoms are mainly pins and needles in the legs along with imbalance (legs do not function well).

The good news is that as long as there is no cord compression, this condition is not dangerous. Chiropractic manipulation can be helpful to manage the symptoms. Since, typically the symptoms occur with prolonged sitting or standing, extension strengthening can be helpful. Lying face-up over an exercise ball to stretch the spine and then lying face-down and doing back extensions (reverse sit-ups) can be helpful.

There are portable seat pads made of sorbothane, a viscoelastic polymer that might be helpful to reduce the vibration imparted by your occupation.

Medications such as membrane stabilizers (Lyrica and Neurontin) can occasionally help with symptoms as long as side effects are minimal. These meds work in about 30% of patients effectively without significant side effects.

Facet blocks can relieve pain. If these blocks temporarily eliminate pain (see facet blocks and keeping a pain diary on the website), you might be a candidate for rhizotomies. Rhizotomies are a more permanent procedure to relieve pain.

If nothing else works, surgery could be considered but that would be if everything fails and the pain is absolutely debilitating. I won’t go into details but surgery is the last resort if nothing else works and a work-up indicates you are a candidate.

Dr. Corenman

Review of the MRI can reveal a solid fusion but the MRI is generally unreliable to ascertain if a solid fusion is present.

He notes mild to moderate degenerative changes at C4-5. This can be a pain generator for neck pain. He reports you have no radicular symptoms. This means you have no arm pain or examination findings of weakness, sensory loss or reflex changes.

Standard X-rays including flexion and extension in your case would be important to determine the presence of degeneration, stability and angulation of the C4-5 level as well as helping to reinforce the understanding of solid fusion at the C5-6 level.

Dr. Corenman

Your complaints are typical for IDR with foraminal collapse. The back pain is most likely from the loss of shock absorption. The episodes of “going out” are typical from certain impact or vibration activities that overload the bony endplates and cause small fractures (not dangerous but painful).

The leg pain is most likely from the loss of height of the foramen. This foramen is the exit zone for the nerve root. The height of the normal foramen is normally at least 50% from the height of the disc. When the disc rebsorbs, this height is lost. To add insult to injury, bone spurs form in the foramen as a result of bone on bone impact which additionally “clogs” this hole.

The foramen actually changes in volume from flexion to extension (bending forward to backward). Forward bending opens this hole and backwards bending narrows it. The acts of standing and walking cause this hole to narrow- further compressing this nerve. Leg pain can develop immediately and last sometimes for days.

Dr. Corenman