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Which One is the Problem?
Shortly before Christmas of '99 I experienced a "catch" in my lower back. I paid a visit to my chiropractor for a little "tune up" and figured I would be good to go. This has worked in the past. Several adjustments later I was feeling worse. The chiropractor did x-rays that showed a curve in lower section of the spine and tilted hips. A very bad day of pain and increased desire to urinate landed me in the emergency room. I was given Flexiril and a high dose of Ibuprofen and told to see my regular doctor if my symptoms weren't better in 5 days. 5 days later my regular doctor told me to cut back on the Ibuprogen and "take it easy". Lumbar x-rays revealed spurs and arthritis on L4 and L5, spondylolitheses of L5-S1. In February I began seeing an Osteopath who prescribed Physical Therapy. This seemed to be helping. After my symptoms flared up again, I had an MRI. This revealed a disc bulge on L4-L5 to the right, with no narrowing of the foramenal opening and a protruding disc on L5-S1 centrally and to the right with a slight narrowing of the foramenal opening. Evaluation of all the data also revealed that my left left is 9 mm longer than the right. Currently I am wearing a 1/4" heel lift and going to Physical therapy.
My symptoms vary from day to day and have included: tingling, mostly in the buttocks but also in the thighs; Cramping in all leg muscles and well as the glutes; periodic increased desire to urinate and deficate; discomfort on the left side of the anal area; back ache across the hips. The symptoms are primarily on the left side. Symptoms are better and mostly non-existent after waking and gradually increase through out the day particlarly after periods of sitting. Sitting is particularly uncomfortable.
I have heard that even mild pressure on nerves for extended perioeds can cause non-reversible damage. I am not sure where to start. I don't know what is cause for concern and what is just uncomfortable. Can you help?
My symptoms vary from day to day and have included: tingling, mostly in the buttocks but also in the thighs; Cramping in all leg muscles and well as the glutes; periodic increased desire to urinate and deficate; discomfort on the left side of the anal area; back ache across the hips. The symptoms are primarily on the left side. Symptoms are better and mostly non-existent after waking and gradually increase through out the day particlarly after periods of sitting. Sitting is particularly uncomfortable.
I have heard that even mild pressure on nerves for extended perioeds can cause non-reversible damage. I am not sure where to start. I don't know what is cause for concern and what is just uncomfortable. Can you help?
The urologist has recommended a CMG. Does this seem like a useful approach? Since Cauda Equina should have shown up on the MRI, is this test going to be non-productive? This test doesn't sound particularly pleasant and I don't really want to have anything that is not necessary.
Thanks very much for the responses. This has been a difficult time and any information I can obtain is helpful in trying to sort out what is going on. Thanks.
Thanks very much for the responses. This has been a difficult time and any information I can obtain is helpful in trying to sort out what is going on. Thanks.
Dear Sue:
Your symptoms are out of line with the MRI findings. I do not know why. Cauda Equina syndrome would have been evident on the MRI and since it wasn't, I don't believe this is what is causing your symptoms. I would hang in there with rehab. In the end, it will have the most benefit. The injection will only indicate if the problem is inflammatory (steriod injection?). Or are they thinking pain medication? I would check with your neurologist before doing this.
CCF Neuro MD
Your symptoms are out of line with the MRI findings. I do not know why. Cauda Equina syndrome would have been evident on the MRI and since it wasn't, I don't believe this is what is causing your symptoms. I would hang in there with rehab. In the end, it will have the most benefit. The injection will only indicate if the problem is inflammatory (steriod injection?). Or are they thinking pain medication? I would check with your neurologist before doing this.
CCF Neuro MD
Based on the findings of the MRI, is Cauda Equina Syndrome something that I need to be concerned with? My D.O. has recommended that I see a urologist to rule out any other urinary problems and then suggested possibly a facet injection. Would it be a good idea to be evaluated by a neurologist before getting the injection? This Cauda Equina Syndrome deals with 'basics of life' issues and is very scary.
I am still trying to sort through all of the different sensations that I have and trying figured out what's causing what. On Saturday (3/25) I began to feel a pressure in the rectal area (as if straining to have a movement).
This lasted for several hours and was followed by a STRONG desire to urinate that did not go away after urination. At one point I urinated 7 times in one hour. This sensation was accompanied by a very heavy feeling in the lower abdomen (as if no amount of "sucking it in" would activate the muscles. Through walking and trying to concentrate on something else, this diminished but did not go away. On Sunday, I had substantial pain on both sides in the small of the back. It subsided when I lay down although it did not go away. I went in for a urinalysis today, but no results yet. Could these sensations be caused either by the L5-S1 disc protrusion or the L5 spondylolithesis?
From the x-rays and MRI that I had, it seems that none of things that I have 'came on all of a sudden'. The spurs, arthritis, spondo and perhaps the bulging disc have all been with me for awhile. I am having a hard time reconciling that fact that one day I am ok, and the next day I am wreck. It seems like I am riding on a pain/syptom merry-go-round and I have not figured out how to get off! Can these sequences of things be self-perpetuating?
In talking to my physical therapist, she says my rehab is going to take a long time. I am getting very depressed about the prognosis and having a difficult time coming to terms with this. I am having difficulty concentrating and find myself cryng at very inopportune times. I know having a positive attitude is essential. But with so little progress and not many answers, It is difficult.
This lasted for several hours and was followed by a STRONG desire to urinate that did not go away after urination. At one point I urinated 7 times in one hour. This sensation was accompanied by a very heavy feeling in the lower abdomen (as if no amount of "sucking it in" would activate the muscles. Through walking and trying to concentrate on something else, this diminished but did not go away. On Sunday, I had substantial pain on both sides in the small of the back. It subsided when I lay down although it did not go away. I went in for a urinalysis today, but no results yet. Could these sensations be caused either by the L5-S1 disc protrusion or the L5 spondylolithesis?
From the x-rays and MRI that I had, it seems that none of things that I have 'came on all of a sudden'. The spurs, arthritis, spondo and perhaps the bulging disc have all been with me for awhile. I am having a hard time reconciling that fact that one day I am ok, and the next day I am wreck. It seems like I am riding on a pain/syptom merry-go-round and I have not figured out how to get off! Can these sequences of things be self-perpetuating?
In talking to my physical therapist, she says my rehab is going to take a long time. I am getting very depressed about the prognosis and having a difficult time coming to terms with this. I am having difficulty concentrating and find myself cryng at very inopportune times. I know having a positive attitude is essential. But with so little progress and not many answers, It is difficult.
Update (3/27). Urinalysis normal. Here are the specific findings of the MRI. (Just got a copy of the actual report)
L1-L2, L2-L3, L3-L4 - No evidence of disk bulge or herniation. The central canal and neural foramen are widely patent.
L4-L5 - Mild broad basssed diffuse disk bulge is identified. There is only minimal effacement of the thecal sac with slight central disk protrusion. The AP canal diameter remains widely patent. The neural foramen are patent. Only minimal facet degenerative changes are identified.
L5-S1 - Disk protrusion is identified eccentric to the right. Some protrusion is also seen centrally. Disk protrusion does cause mild right neural foramenal entrance opening. Mild facet degenerative changes are evident.
S1-S2 - No evidence of disk bulge or herniation. Minimal central protrusion is noted.
Impression: Mild right neural foramenal entrance stenosis at L5-S1.
Does any of this make sense with the symptoms I am having?
L1-L2, L2-L3, L3-L4 - No evidence of disk bulge or herniation. The central canal and neural foramen are widely patent.
L4-L5 - Mild broad basssed diffuse disk bulge is identified. There is only minimal effacement of the thecal sac with slight central disk protrusion. The AP canal diameter remains widely patent. The neural foramen are patent. Only minimal facet degenerative changes are identified.
L5-S1 - Disk protrusion is identified eccentric to the right. Some protrusion is also seen centrally. Disk protrusion does cause mild right neural foramenal entrance opening. Mild facet degenerative changes are evident.
S1-S2 - No evidence of disk bulge or herniation. Minimal central protrusion is noted.
Impression: Mild right neural foramenal entrance stenosis at L5-S1.
Does any of this make sense with the symptoms I am having?
Dear Sue:
I am confused with the leg measurements, does it mean that you do not have a longer leg on one side? Gait analysis is where we assess how you walk and the compensations you might make if you had a longer leg, or muscle weakness etc. Alot of gait problems can cause back ache. Based on your symptoms and MRI there is not an equivocal relationship. I think rehab sounds like a very good thing. I would see a neurologist and try to sort out what is seen on the MRI compared to your symptoms.
Sincerely,
CCF Neuro MD
I am confused with the leg measurements, does it mean that you do not have a longer leg on one side? Gait analysis is where we assess how you walk and the compensations you might make if you had a longer leg, or muscle weakness etc. Alot of gait problems can cause back ache. Based on your symptoms and MRI there is not an equivocal relationship. I think rehab sounds like a very good thing. I would see a neurologist and try to sort out what is seen on the MRI compared to your symptoms.
Sincerely,
CCF Neuro MD
Subsequent conversations with my D.O. have cleared up the fact that the 9 mm referred to the discrepency in the sacral base and was a measurement taken from scoliosis radiographs and was not from actual leg measurements. What exactly is the "gait assessment" that you referred to?
Less than 4 months ago I was a very active individual; building a shop with my husband, caring for our 2 acre yard and pretty much doing anything I wanted to. Now putting my socks on in the morning is a challenge. I am willing to work at therapy like I have never worked at anything in my life to help maintain my lifestyle. I realize I have not always practised the best body mechanics in the world and have much room for improvement there. Do have any thoughts on the prognosis for someone with my laundry list of "troubles"?
Less than 4 months ago I was a very active individual; building a shop with my husband, caring for our 2 acre yard and pretty much doing anything I wanted to. Now putting my socks on in the morning is a challenge. I am willing to work at therapy like I have never worked at anything in my life to help maintain my lifestyle. I realize I have not always practised the best body mechanics in the world and have much room for improvement there. Do have any thoughts on the prognosis for someone with my laundry list of "troubles"?
Dear Sue:
I think I would first begin with an assessment of your gait. Once that has been corrected or noted to be fine, then I think the correct procedure is physical therapy and rehab. By the description, there is no cord compromise. The narrowing of the foramen is likely due to stress because of the differences in leg length inducing irritation of the nerve as it passes through the foramen. There is little to do about the narrowing of the foramen, but through rehab and gait adjustment, I would imagine that you can improve the pain and irritiation of the nerves.
Sincerely,
CCF Neuro MD
I think I would first begin with an assessment of your gait. Once that has been corrected or noted to be fine, then I think the correct procedure is physical therapy and rehab. By the description, there is no cord compromise. The narrowing of the foramen is likely due to stress because of the differences in leg length inducing irritation of the nerve as it passes through the foramen. There is little to do about the narrowing of the foramen, but through rehab and gait adjustment, I would imagine that you can improve the pain and irritiation of the nerves.
Sincerely,
CCF Neuro MD
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