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in reply to: Herniated Disc at L4-L5 and L5-S1 #4919
You had a back injury about 5 months ago at work that apparently has not improved at this point. Your pain is lower back and well as left buttocks down the leg. You have had a CT scan without a myelogram that demonstrated a 1 mm HNP at L4-5 and a 4 mm HNP at L5-S1.
Let’s start at the beginning. What is the percentage of your pain in the lower back vs. the buttocks and leg? 60/40, 70/30, or the reverse? What makes your pain better and worse? Walking, standing, bending, sitting, lying down? You note weakness in your left leg. It is because of pain inhibition or true weakness (can’t get the muscle to fire with or without pain)?
What side is the larger disc herniation spotted by CT scan? Did you get temporary relief from the epidurals (the first 2-3 hours) or was that time period data not recorded (pain diary- see website).
Where is your headache after the epidural? Front of the head, eyes, back of the head, base of the neck?
I need more information.
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.in reply to: Hamstring & leg pain #4917First- let’s establish the symptoms you suffer from. You have cramping in your hamstrings and calf muscles with walking a short distance. Are the symptoms bilaterally equal or is there much more on one side than the other? Can you walk the exact same distance every time or are there days you can walk further and others that you can’t? If you sit or lie down, do your symptoms go away? If you are at a supermarket and hold onto a shopping cart, can you walk further comfortably?
Are these symptoms actually muscle cramps or pain that feels like muscle cramping? Do you get this cramping in any other muscle groups, especially in your arms? You note that you can work out on an elliptical machine and do not get onset of symptoms- at least for a longer time. Are you bent forward when you work out?
Has someone looked at your feet to see if there are pulses present? Are your feet discolored or swollen? Do you have ankle swelling? Have you lost hair on your feet and are your toenails thickened?
All these questions differentiate vascular claudication from neurogenic claudication (see web site). You very well might have spinal stenosis which leads to neurogenic claudication but your differential is still not established (again- see website).
Assuming neurogenic claudication, a great test and treatment is an epidural steroid injection. If you get good relief, even for a short period of time, this might confirm the diagnosis. You might even get long term relief (3 months or more). Now- if we assume the presence of neurogenic claudication, you might be a candidate for surgical decompression but that depends upon many factors including the spinal stability and your ability to undergo the surgery.
Your MRI does note the presence of central stenosis which certainly can cause your symptoms, especially at L4-L5.
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.in reply to: Lower back pain due to hernaited disc? #4915You have lower back pain that radiates into your left buttocks and occasionally radiates below your left knee. You do not mention when the onset of pain occurred. Was it gradual or immediate as the result of an action like lifting? Did you have long standing intermittent lower back pain that increased recently? Is the buttocks and leg pain newer onset or just increased in intensity?
Is the lower back pain or the leg pain worse and by what amount? Example- 60% low back pain and 40% buttocks and leg pain or 70/30 or 30/70? What makes the low back and leg pain worse? Standing vs. sitting vs. lifting vs. walking vs.???????????
Your MRI notes degenerative disc disease at L3-4, L4-5 and L5-S1. You have a rather large herniated disc at L4-5 which fills up about a third of the canal and is compressing the L5 nerve root on the left. That explains your leg pain. Your lower back pain could be from the three degenerative discs, the herniation itself, stenosis from the herniation (see web site) or even the facets.
I don’t know what facilities you have there but an epidural steroid injection and physical therapy are the initial tools I use for this disorder in the beginning. You may eventually need surgery but if you have no motor weakness, the conservative route is the one to take in the beginning. To test for motor weakness, simply heel walk (duck walk) around the room. If your left forefoot stays off the ground with prolonged walking, you have no significant motor weakness. If you have weakness, surgery should be considered.
By the way- using flicker to show your images worked very well. That was a great idea.
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.in reply to: Disagreement on Degree of Surgery Needed #4914By your description, your C6 nerve root is functioning properly (biceps curls are equal right to left). It appears that you do not put your neck in jeopardy so the stenosis does not post a significant risk, especially if the stenosis is moderate and not severe.
A one level ACDF should decompress the C7 root and give the best chance of arm pain relief and motor strength return. It sound like you are on the right track.
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.in reply to: Disagreement on Degree of Surgery Needed #4910Pain in the teres minor and levator scapulae muscles is most commonly referral point from facets, discs or from nerve irritation. The EMG which confirms triceps denervation indicates a C7 nerve compression. The teres minor weakness is unusual by itself as this muscle is innervated by the axillary nerve from C5 and/or C6. This might indicate the higher nerve roots being compressed but you should also notice weakness in wrist extension and biceps if C6 was involved and deltoid weakness if C5 were involved (holding your shoulder up against resistance).
The MRI reading is appreciated but remember that modifiers are in the eye of the beholder. “Moderate canal stenosis” to one radiologist might be “severe” or even “mild” to another.
Let’s talk about central stenosis. If the cord is compressed significantly, you do have a somewhat greater chance of central cord syndrome with an injury (see website for that description). This injury occurs when you fall and hyperextend your head (impact to the forehead forcing your head backwards). If you do not participate in activities that put you at risk for neck extension (snow skiing, mountain biking, water skiing, horseback riding, contact sports, etc…) then the stenosis is not that important for injury risk.
If however you do participate in sports that put your neck at risk, the danger of injury has to be factored into the need for surgery to remove the stenosis.
Your arm pain and weakness is from foraminal stenosis causing compression of the various nerve roots. Unfortunately, you have multiple levels of foraminal stenosis and at least C5-6 and C6-7 seem to be symptomatic.
So- to a conclusion without a history or physical examination (a far leap of faith), if you had the C5-7 levels fixed, you would be left with C3-4 central stenosis and C4-5 central and foraminal stenosis. You might be able to consider an artificial disc for one level (much depends upon exam and x-rays) or even a combination procedure involving and ACDF, an artificial disc and even a possible posterior decompression (laminectomy, laminoplasty or foraminotomy). Your X-rays including flexion and extension will help. Much depends upon your activity level, your expectations and your physical examination along with personal review of your MRI images.
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.in reply to: Disagreement on Degree of Surgery Needed #4908Let’s break down this fusion decision into its parts. Your complaint is minimal neck pain and right triceps weakness. You have paresthesias into the right middle three fingers. You question a right foot drop.
The right foot drop is highly unlikely to be derived from your neck. You have insignificant neck pain so you would not be getting a fusion for neck pain. It boils down to right triceps weakness and paresthesias into the right middle fingers. This sounds like a right C7 nerve root compression. This is good reason to consider a one level fusion of C6-7 (ACDF- see website). Now, if there is instability or cord compression or even significant root compression of the levels above, there might be reason for extending the fusion up.
I don’t have the films, your history or your physical examination to help with that determination. Generally- you proceed with fusion for correction of nerve compression, cord compression, deformity or instability. I can’t determine what disorders you have other than a C7 radiculopathy by your descriptions. Just remember- smaller is generally better.
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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