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#32153 In reply to: When to consider surgery |
To give a little more information, the sciatic episodes are intense with sharp shooting pain in the butt radiating to back of thigh. With these episodes I have difficulty sitting and standing up. These episodes last about 2 weeks. Once they calm down, I have the intermittent butt ache, back stiffness, and occasional achey pain down my hamstring.
MRI results w & w/o contrast
Findings: There is a transitional vertebrae at the superior sacral level, for the purposes of numbering of lumbar vetrebrae this will we referred to as S1
T1-L3 – no significant posterior disc abnormality or stenosis, bony hemangioma noted in the L3 vertebral body
L3-4 there is a broad based posterior disc protrusion, assymetric slightly more prominent on the right than left side. There is a moderate degree of central canal stenosis, Degenerative facet arthrodosis and ligamentum flaven hypertrophy is present. Moderate left and mild right foraminal stenosis is present.
L4/5 there is a left sided posterior disc herniation with extrusion of disc material that extends cephalad along the posterior margin of thevleft side of the L4 vertebral body. There is a moderate degree of central canal stenosis, Degenerative facet joint arthrosis is present. Degernerative endplate signal changes seen, particularly on left side. Moderate right and moderate to severe left foraminal stenosis present.
L5/S- Mild anterolisthesis present, metallic density seen in the disc space. Mild right and moderate degree of left foraminal stenosis, Degenerative facet changes are noted. No central canal stenosis noted, there has been prior bilateral laminectomies at this level.(note it was a 360 fusion, posterior hardware was removed)Following gandolinium administration, minimal enhacing scar seen along posterior margin of the L5 vertebral body
It has been 6 yrs since my L5/S1 fusion for isthmic spondylolisthesis,and outcome was good. Then significant symptoms of ASD started 15 months ago. At that time the Xrays showed mild retrolithesis at L4/5, MRI had revealed L4/5 herniation L3/4 disc bulge and multilevel spondolytic disease. I have a dextroconvex scoliotic curve of approx 20% eith a rotation as well at L3-5.
I now have axial pain, groin pain, unilateral left sided radiating nerve pain from spine to left wrapping around hip to lateral thigh and shin, with severe relentless spasms in gluteal and quadricep muscles. My leg buckles when walking, and the pain is not relieved by rest, NSAID, muscle relaxants and Percocet 10, all taken together. The muscle spasms are new and after declining with back pain, with some radicular, the pain hit a level where I cannot sleep or function.
Do you think I should agree to a discectomy or extension fusion surgery? I postponed having surgery with first acute episode(s) 14/15 mos ago, but regret now. I have been given conflicting advice, one surgeon said I needed an extension fusion (posterior/lateral) another said multilevel discectomy /hemilaminectomies would suffice.
What surgerical approach gives me the most opportunity to improve? I know I will not have pain free time sans sleep, it is unreasonable. I just want the best possible functional outcome that enables me to go to work hopefully uninterrupted for a couple of years.
#32144 In reply to: Parsonage Turner Syndrome |Dr. Corenman-
Thank you for the quick reply. Extension of the neck does not seem to increase the symptoms. The doctor I saw stated that if the symptoms did not improve over a span of a couple weeks that he would consider doing an MRI, CT, and/or EMG.Again, thank you for a quick reply and giving me some things to consider.
-Mindy#32143Topic: What surgical management options do I have for lumbar ASP? in forum BACK PAIN |I had an L5/S1 360 fusion for isthmic spondylolisthesis, the outcome was good until the dreaded ASD.
5 yrs later painful adjacent segment pathology became incapacitating at L3-5. MRI revealed L4/5 herniated, L3/4 had bulge, both levels had spondolytic changes. I had 2 episodes requiring narcotics, muscle relaxers and bed rest. Then was able to manage, become somewhat active, and used NSAIDs/ice.
15 months later, L4/5 extruded, there are fragments under L4 nerve root (left side) L3/4 herniated to the right, have severe left, moderate right foraminal stenosis at both levels, central canal stenosis, facet joint hypertrophy, infolding of ligamentum flaven, a good amount of disc height loss and grade 1 retrolithesis.
My symptoms started up again with awful axial pain first radiating to left, then bilaterally. Then within a month of onset of the severe pain, I woke up with vice like left leg muscle spasms in gluteal and quadricep muscles, my knee is buckling, have left side groin pain and saddle numbness, and radicular pain radiating around left hip to lateral thigh and crossing over my shin. No narcotic or muscle relaxer is providing any relief. ESIs are contraindicated.
I need to make a decision quickly as to what surgical approach to consent to. I am 46yo, BMI ~21, have connective tissue/ automimmune disease, suspected collegen defect based upon hyperextensive joints, so know my genetics play into my condition. Not to be construed as “medical advice” but just looking for help since I have received conflicting opinions. I am leaning towards a posterior full decompression with lateral fusion, knowing the continued risks of further ASD. However one surgeon mentioned discectomy, vs extension fusion.
I fear that more surgery would be likely at the same levels and that statistically my chances of a good outcome decline with further surgeries at the same levels, and having postetior scar tissue if further surgery is needed. Is my thought process reasonable, or should I go with the “deal with disks hemi-laminectomiesonly approach in your opinion?
#32137 In reply to: Help with MRI results |This was the 1st MRI from Aug 2018
Technique: Sagittal T2, sagittal T1, sagittal STIR, axial T2.There is a transitional lumbar sacral junction with partially
sacralized right L5 vertebral body. Vertebral height is maintained.At L5/S1, no disc bulge or lateralizing disc herniation is present.
At L4/L5, no disc bulge or lateralizing disc herniation is present.
At L3/L4, there is mild disc space narrowing with small anterior
marginal osteophyte formation. There is a small 1.2 cm in height by 5
mm in AP by 5 mm in transverse dimension right subarticular inferior
disc extrusion extending to the mid L4 vertebral body (series 6,
images 7-8). Disc herniation causes mild narrowing of the right
lateral recess with mild impingement of the subarticular right L4
nerve root. Bulging disc causes minimal inferior foraminal
encroachment.At L2/L3, there is disc desiccation with mild disc space narrowing and
small anterior marginal osteophyte formation. Bulging disc causes
minimal thecal impression and minimal inferior foraminal encroachment.At L1/L2, there is disc desiccation with tiny Schmorl’s nodes and tiny
anterior marginal osteophyte formation. There is minimal posterior
bulging of the annulus. No limiting central or foraminal stenosis is
present.At T12/L1, there is disc desiccation. Small left paracentral disc
protrusion causes mild thecal impression without neural impingement or
limiting central stenosis.At T11/T12, there is a shallow central disc protrusion causing minimal
thecal impression.The conus terminates at T12/L1 and is normal in signal and in caliber.
Localizer images demonstrate an indeterminant 2.5 cm in height right
lateral renal lesion possibly a renal cyst.IMPRESSION: MRI lumbar spine.
1. Transitional lumbar sacral junction.
2. Small right subarticular inferior disc extrusion at L3/L4 causes
mild impingement of the subarticular right L4 nerve root coursing
through the right lateral recess.
3. Small left paracentral disc protrusion at T12/L1 and shallow
central disc protrusion at T11/T12 cause minimal to mild thecal
impression without neural impingement or limiting central stenosis.
4. Indeterminant 2.5 cm right lateral renal lesion possibly a renal
cyst. Correlation with patient’s outside abdominal imaging suggested.
If none are available then renal ultrasound could be performed to
confirm cystic nature. 8/7/2018This is the cervical and lumbar MRI from Dec 2018
From the skull base to T4 was imaged. There is mild cervical scoliotic
positioning convex towards the right. Vertebral height is maintained.At C2/C3, minor left-sided uncovertebral joint hypertrophy is present
without causing significant foraminal encroachment.At C3/C4, uncovertebral joint hypertrophy results in mild thecal
impression and minimal left foraminal narrowing.At C4/C5, there is mild disc space narrowing with tiny anterior
marginal osteophyte formation. There is a broad-based disc osteophyte
complex effacing the ventral and dorsal subarachnoid space slightly
deforming the ventral cord. The central canal is narrowed to an AP
diameter of approximately 8.8 mm. Uncovertebral joint hypertrophy
results in severe bilateral foraminal stenosis.At C5/C6, there is mild disc space narrowing with small anterior
marginal osteophyte formation. There is a bulging disc with
spondylitic ridging contacting the ventral cord. The central canal is
minimally narrowed to an AP diameter of approximately 9.6 mm.
Uncovertebral joint hypertrophy results in severe bilateral foraminal
stenosis.At C6/C7, there is mild disc space narrowing with small anterior
marginal osteophyte formation. Bulging disc causes mild thecal
impression. Uncovertebral joint hypertrophy results in severe left
foraminal stenosis.At C7/T1, bulging disc causes minimal thecal impression.
At T1/T2, small right paracentral disc protrusion causes mild thecal
impression without cord impingement.At T2-T3, shallow right paracentral disc protrusion causes minimal
thecal impression.At T3/T4, bulging disc with spondylitic ridging contacts the ventral
cord. The dorsal subarachnoid space is maintained.No intrinsic cord signal abnormality is identified. Cervical medullary
junction appears unremarkable. Paraspinal soft tissues appear
unremarkable.IMPRESSION:Noncontrast MRI cervical spine.
1. Cervical scoliotic positioning convex towards the right.
2. Mild cervical and proximal thoracic spondylosis.
3. Small disc osteophyte complexes cause mild thecal impression with
minimal to mild narrowing of the central canal at C4/C5 and at C5/C6.
No evidence for underlying cord signal abnormality.
4. Uncovertebral joint hypertrophy results in prominent bilateral
foraminal stenosis at C4/C5, bilaterally at C5/C6 and on the left at
C6/C7 with neural impingement.PROCEDURE: Contrast-enhanced lumbar spine MRI.
There is a transitional lumbar sacral junction with partially
sacralized right L5 vertebral body. Vertebral height is maintained.
There is a minor lumbar levoscoliosis.At L5/S1, no disc bulge or lateralizing disc herniation is present.
At L4/L5, no disc bulge or lateralizing disc herniation is present.
At L3/L4, there is mild disc desiccation with mild disc space
narrowing and small anterior marginal osteophyte formation. There is
evidence of interval right hemilaminectomy with resection of inferior
right-sided disc extrusion. Bulging disc with enhancing posterior
annular fissure causes minimal thecal impression and minimal inferior
foraminal encroachment. There is mild facet arthropathy with trace
facet joint effusions. Mild enhancing granulation tissue is identified
within the laminectomy bed.At L2/L3, there is disc desiccation with mild disc space narrowing and
small anterior marginal osteophyte formation. There is a bulging disc
causing minimal thecal impression and minimal inferior foraminal
encroachment, unchanged.At L1/L2, there is disc desiccation with tiny Schmorl’s nodes and
small anterior marginal osteophyte formation. There is minimal
posterior bulging of the annulus slightly eccentric towards the left
without causing neural impingement or limiting central stenosis. No
significant foraminal narrowing is present.At T12/L1, tiny Schmorl’s nodes are present. There is a small left
paracentral disc protrusion causing mild thecal impression without
neural impingement, unchanged. Neuroforamina are patent.At T11/T12, there is a shallow central disc protrusion causing minimal
thecal impression, unchanged.The conus terminates at T12/L1 and is normal in signal and in caliber.
There is again evidence of a 2.6 cm in height T2 hyperintense lesion
within the lateral midpole of the right kidney probably a renal cyst,
unchanged.IMPRESSION:Contrast-enhanced lumbar spine MRI.
1. Transitional lumbar sacral junction.
2. Interval right hemilaminectomy at L3/L4 with resection of inferior
right-sided disc extrusion.
3. Stable small left paracentral disc protrusion at T12/L1 and
shallow central disc protrusion at T11/T12 causing minimal thecal
impression.
4. Possible small right lateral midpole 2.6 cm renal cyst.
Correlation with patient’s outside abdominal imaging suggested. If
none are available then renal ultrasound could be performed to confirm
cystic nature.This is the cervical MRI from a couple of weeks ago
Comparison is made with previous examination dated 1/8/2019.
Procedure: Noncontrast MRI cervical spine.
From the skull base to the mid T4 vertebral body was imaged. There is
mild cervical scoliotic positioning convex towards the right.
Vertebral height is maintained.At C2/C3, minor left-sided uncovertebral joint hypertrophy is present
without causing significant foraminal encroachment.At C3/C4, there is a shallow left paracentral disc osteophyte complex
contacting the ventral cord. The dorsal subarachnoid space is
maintained. Uncovertebral joint hypertrophy results in minimal left
foraminal narrowing, unchanged.At C4/C5, there is mild disc space narrowing, tiny Schmorl’s nodes and
tiny anterior marginal osteophyte formation. There is a broad-based
disc osteophyte complex effacing the ventral and dorsal subarachnoid
space slightly deforming the ventral cord. The central canal is
narrowed to an AP diameter of approximately 8.6 mm compared with 8.8
mm, previously. Uncovertebral joint hypertrophy results in severe
bilateral foraminal stenosis, unchanged.At C5/C6, there is mild disc space narrowing with small anterior
marginal osteophyte formation. There is a broad-based disc osteophyte
complex slightly eccentric towards the right contacting the ventral
cord. The dorsal subarachnoid space is maintained. The central canal
is minimally narrowed to an AP diameter of approximately 9.6 mm,
unchanged. Uncovertebral joint hypertrophy results in severe bilateral
foraminal stenosis, unchanged.At C6/C7, there is mild disc space narrowing with small anterior
marginal osteophyte formation. Bulging disc causes mild thecal
impression without cord impingement or limiting central stenosis.
Uncovertebral joint hypertrophy results in severe left foraminal
stenosis, unchanged.At C7/T1, bulging disc causes mild thecal impression.
At T1/T2, small superior right paracentral disc extrusion causes mild
thecal impression without cord impingement. Disc herniation has
slightly increased in size when compared to previous examination.At T2/T3, shallow right paracentral disc protrusion causes minimal
thecal impression, unchanged.At T3/T4, bulging disc with spondylitic ridging contacts the ventral
cord. The dorsal subarachnoid space is maintained.No intrinsic cord signal abnormality is identified. Cervical medullary
junction appears unremarkable. Paraspinal soft tissues appear
unremarkable.IMPRESSION:Noncontrast MRI cervical spine.
1. Mild cervical scoliotic positioning convex towards the right be
secondary to muscular spasm or patient positioning.
2. Stable cervical spondylosis with small disc osteophyte complexes
causing minimal cord impingement and narrowing of the central canal at
C4/C5 greater than than at C5/C6. Central canal stenosis has slightly
increased at C4/C5. No evidence for underlying cord signal
abnormality.
3. Slight interval increase in size of right-sided disc herniation at
T1/T2 causing mild thecal impression without cord impingement.
4. Uncovertebral joint hypertrophy again results in multilevel
prominent foraminal stenosis, unchanged. 2/13/2020#32134 In reply to: Neck And back Issues |You note “I’ve had neck and shoulder pain for about 4 years” You have good reason for the pain.
C4-C5: Moderate disc space narrowing…. Severe right facet arthropathy with evidence of acute inflammation…C5-C6: Moderate to severe disc space narrowing with posterior disc osteophyte complex …resulting in moderate to severe left and mild-to-moderate right foraminal narrowing”.Severe right facet arthropathy at C4-5 will cause local significant pain on the right, especially with right lateral bending and extension of the neck. C5-6 has significant foraminal stenosis which will compress the C6 nerve root. See https://neckandback.com/conditions/symptoms-of-cervical-nerve-injuries/
You then note “In the middle of all this, I started having lower back, hip and buttock pain. It has progressed to pain in my legs and a lot of foot numbness”. The source for this is obvious.
“L4-L5: Grade 1 anterolisthesis of L4 on L5…contribute to severe spinal canal stenosis”.This is a typical degenerative spondylolisthesis at L4-5 with severe spinal stenosis. You could try an epidural steroid injection and probably gain some relief but you probably are headed for surgery. See https://neckandback.com/conditions/degenerative-spondylolisthesis-or-spondlylolysthesis/ and https://neckandback.com/conditions/lumbar-spinal-stenosis-central-stenosis/
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. -
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