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Neurology (Expert Forum)
surgery?
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surgery?
by djam, Apr 01, 2003 12:00AM
I've been having chronic low back and mid-back pain for almost two years. The pain is constant with moderate pain that's increased to severe sharp pain depending on whether I twist or bend a certain way. I have had a couple of MRI's and a Discogram with CT scan that show the following:
1998-MRI showed a mild bulge at L4,L5 level that minimlly indents the Thecal Sac. L4-L5,L5-S1 shows mild disc height. No spinal Stenosis.
2001-MRI showed DDD at L4-L5 with a broad-based disc bulging. L5-S1 showed DDD with mild disc bulging. Again no Spinal Stenosis or evidence of significant Facet Arthopathy.
Discogram-Jan. 2003 Showed L3-L4-Minimal non-concordant pain, normal disc morpholoy.L4-L5, pain was concordant with right sided as well as left sided pain elicited. The disc morphology was flattened pancake apperance with some posterior fisuring noted. L5-S1, pain was located only on left hand side in a concordant fashion. Disc apperance was flattened pancake morpholoy with posterior fissuring seen. Disc is positive.
CT-Scan which was taken immediately after the Discogram only showed the narrowing of the disc with no Spinal Stenosis or evidence of Foraminal narrowing and there was no evidence of extension of contrast material through the Annulus of any of the injected levels.
Based on the Discogram results, and the chronic symptoms, my immediate Orthopaedic doctor and the doctor who performed the Discogram are recommending a discectomy with interbody fusion at both level L4-L5 and L5-S1. I don't qualify for IDET since my discs showed severe narrowing. Your opinion, please.
1998-MRI showed a mild bulge at L4,L5 level that minimlly indents the Thecal Sac. L4-L5,L5-S1 shows mild disc height. No spinal Stenosis.
2001-MRI showed DDD at L4-L5 with a broad-based disc bulging. L5-S1 showed DDD with mild disc bulging. Again no Spinal Stenosis or evidence of significant Facet Arthopathy.
Discogram-Jan. 2003 Showed L3-L4-Minimal non-concordant pain, normal disc morpholoy.L4-L5, pain was concordant with right sided as well as left sided pain elicited. The disc morphology was flattened pancake apperance with some posterior fisuring noted. L5-S1, pain was located only on left hand side in a concordant fashion. Disc apperance was flattened pancake morpholoy with posterior fissuring seen. Disc is positive.
CT-Scan which was taken immediately after the Discogram only showed the narrowing of the disc with no Spinal Stenosis or evidence of Foraminal narrowing and there was no evidence of extension of contrast material through the Annulus of any of the injected levels.
Based on the Discogram results, and the chronic symptoms, my immediate Orthopaedic doctor and the doctor who performed the Discogram are recommending a discectomy with interbody fusion at both level L4-L5 and L5-S1. I don't qualify for IDET since my discs showed severe narrowing. Your opinion, please.
Doctor's Answer
by CCF-Neuro-M.D.-JT, Apr 03, 2003 12:00AM
It's extremely difficult if not impossible to accurately comment on the need for surgical intervention without examining your or personally reviewing your films. Typically, the most important things we look for on an MRI of the spine as a neurologist include the integrity of the spinal cord and the nerve roots that exit from it. Of course, the actual spine and discs are important also, but we take it into account with the cord and nerves in this specific setting, e.g. is the disc pushing on the cord, is there enough room for the nerve in the foramina (bony passage that the nerve goes thru as it exits the cord). It's very possible that the degree of disc degeneration may be a significant cause of your symptoms. But from your description of the diagnostic findings, there does not appear to be any significant compromise of the nerves or cord. Other important things we use to help us decide about surgery include any objective neurological findings such as weakness (like a footdrop) significant numbness that is getting worse and can be attributed to a back problem and bowel/bladder complaints. Sometimes, we need to do an EMG to further characterized the degree of nerve damage and localize the problem. All of these factors are important in helping the patient decide whether or not to undergo surgery.
Surgery is a major decision that you will ultimately have to make with the doctors who have seen you and know your case well. We often have to tell our patients to keep in mind that it's possible that the pain will not go away completely or sometimes not at all after surgery. If you have any doubts as to the need for surgery, get a second opinion at a major academic center by a neurosurgeon or orthopod who specialized in the spine. iF you are in the area, Drs. Benzel, Kalfas, and Whitfield are excellent spine neurosurgeons here at the clinic. Bring your films with you. Best of luck.
Surgery is a major decision that you will ultimately have to make with the doctors who have seen you and know your case well. We often have to tell our patients to keep in mind that it's possible that the pain will not go away completely or sometimes not at all after surgery. If you have any doubts as to the need for surgery, get a second opinion at a major academic center by a neurosurgeon or orthopod who specialized in the spine. iF you are in the area, Drs. Benzel, Kalfas, and Whitfield are excellent spine neurosurgeons here at the clinic. Bring your films with you. Best of luck.
All conservative treatments(PT,Vioxx,Bextra,Vicodin,Robaxin,etc.)didn't work. I have this pain 24/7 and it increases with activity,ie,lifting, walking or when I move a certain way, as explained on my original post. Pain is felt mostly on my left side. At times I hear popping or bone rubbing sound that may increase the pain level.
My mid-back pain is also constant and chronic. I developed the pain during a PT session for my low-back pain. An MRI was taken
which showed mild disc bulges with minimal indentation of the spinal cord at c4-c5 and c5-c6. The sharp pain increases when I try to lift my right arm upright or if I try to turn right. The pain is felt only on the right side, mid-back with constant burning that increases with activity. Doctors have told me that the mid-back pain is related to my low-back condition but I'm hesistant in believing this. At times when my low back pain is moderate, my mid-back is severe and vice versa. Aside from the MRI, is there any other test that I can take. The condition seems to be getting worse in that now I'm getting some numbness and/or pain of my left arm. Thank you for time and service.
Djam