SpinelessWench

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,

I was fairly confident that I’d posted my last question to you, however there’s been a recent development in my situation and I wanted your input. Given the less-than-informative visit to the 2nd opinion orthopedist, whose glance at my MRI revealed “absolutely no stenosis”, I decided the other day to contact the neurosurgeon who has performed four of the nine surgeries I’ve had on both my lumbar and cervical spine. This surgeon has known me for 24 years, and is more than familiar with my spine. We have always had an incredible doctor / patient rapport, and I respect him immensely. He’s also an excellent diagnostic “detective”, and will consider every neurological etiology imaginable as a potential instigator for a patient’s symptoms. We spoke by phone a few days ago, and I summarized not only my current lower lumbar / extremity pain, but the wide variation in possible diagnoses and interpretations of my MRI images.

He immediately offered a possibility as to the cause of my symptoms, and also told me that many orthopedists and neurosurgeons alike oftentimes fail to consider it (most often inadvertently, or simply because it’s off their diagnostic radar). He then told me that my symptoms were classic for stenosis, yet the problem may lie in the sacral plexus region. My MRI did not include the sacral ala, the iliac joint, or anterior views of the joints below S1, so prior surgeons were unable to even consider this component of my spine. He then mentioned that recent neuro-orthopedic research is now beginning to focus on the sacrum as an overlooked culprit of severe lumbar pain, lower extremity pain, and radiculopathy. “When surgeons hear these symptoms”, he said, “many automatically start looking at the disks and foraminal outlets at and above L-5, so they can actually miss the problem because it’s just out of view on the images or X-rays.” He then instructed me to send the MRI, along with a very concise list of my symptoms… I was obviously grateful that he offered to do this.

MY QUESTION FOR YOU:

My low lumbar pain is severe (> 8 all the time) and is bilaterally diffuse across what I can only estimate to be about 2 inches above the top of the “butt crack” (I’m sure there’s a medical term for butt crack, but I didn’t bother to Google it first)… This pain then radiates bilaterally down both legs, but is NOT in the posterior thigh. The pain originates in the sacral band across my low back, then migrates around to the anterior upper thigh/groin. It then travels down the anterolateral thigh, to the lateral knee, then down the lateral leg to about mid-calf, also lateral. Occasionally, it migrates to the lateral ankles and into my feet. The only parasthesias I notice are tingling in the soles of the feet. I also have severe neurogenic claudication. Relief is attained by flexion. I have no bladder or bowel issues, nor is there saddle anesthesia. I also experience sudden, and extremely painful “taser gun” sensations in both hips at the top of the buttocks, which occur suddenly while standing or walking.

Do these symptoms correlate with sacral plexus nerve outlets, and is it possible that a patient can develop degenerative issues in this sub-lumbar area? What are the symptoms associated with SI involvement or the sacral extraforaminal ventricles? And, if there is nerve compression in these sacral outlets, what is the typical surgical technique?

I really appreciate your help. I have a suspicion that my long-time neurosurgeon may be on to something.

S.W., NC

ADDITIONAL QUESTION REGARDING INSTABILITY:

I’d failed to mention an additional symptom in relation to my HX above..

1. At times, while in bed, I’ll lie on my left side, then prop myself up on my left elbow… So, my left hip downward is on the mattress, and my waist (and above) is suspended off the mattress.

2. At times, I’ll hear a muffled, yet tenable, “crack” in my lumbar area around the fusion region. It can only be metaphorically described as an internal “knuckle cracking” sound… I apologize for the weird analogies..

3. At the same time, there is a definite “shifting” sensation, as if the fused area subtly adjusts itself… This shifting, and muffled crack, are simultaneous, and are accompanied by a jolt of pain.

4. There is no attendant parasthesias… Only isolated pain at the area this occurs.

Now, I know that fusions are intended to prevent motion, stabilize an unstable area, and stop things like this… And, my surgeons have all indicated that my fusions appear solid, with no arthrosis apparent since the fusion revisions in 2008.

These shifting and cracking sensations aren’t “all in my head”, or imagined. Any suggestions as to whether this could be evidence of some arthrosis or instability not yet noticed on imaging?

Thanks, one more time.

S.W., NC