Does my MRI indicate surgery is necessary to prevent paralysis?

Hopefully out there someone will read this that has had similar problems and can give me insight.

I am trying to determine if my MRI findings indicate possible paralysis if I do not have surgery.  Currently I am managing pain with Oxycodone 10 325, am daily doing physical therapy, and try to fit in exercise in the pool at least twice a week.

Here is what my recent MRI had:

T12-L1:  Moderate loss of disk height and disk desiccation without spinal canal stenosis or foraminal narrowing.

L1-2:  Broad-based disk bulge noted.  This finding narrows the thecal sac to 5 mm consistent with a least moderate stenosis.  There is also secondary bilateral  at least mild foraminal narrowing.  Mild facet arthrosis.

L2-3:  Mild loss of disk height and disk desiccation without spinal canal stenosis or foraminal narrowing.  Mild facet arthrosis.

L3-4:  Grade 1 anterolisthesis of L3 on 4 with broad-based dis bulge again noted.  Finding does again cause severe spinal canal stenosis, narrowing the thecal sac to 4 mm and displacing it to the left.  Severe facet hypertropic arthrosis is noted.  There is significant right-sided foraminal narrowing also noted.

L4-5:  Severe facet arthrosis.  No evidence of spinal canal stenosis noted, although there does appear to significant left-sided foraminal narrowinng.

L5:S1:  Bilateral L5 pars defects with at least grade 1 anterolisthesis of L5 on S1.  There is broad-based disk bulge with annular tear again noted.  There is secondary significant bilateral formaninal narrowing.

I have back pain 24/7, and am beginning to develop numbness in my left thigh, and nerve pain in my buttocks and going down the back of my legs.  Obviously my conditions did not develop overnight, but over a course of several years.

So, is all the pain coming from all of that foraminal narrowing and facet arthrosis occurring at many levels?  Does the severe stenosis contribute to this?  I will again see an orthopedic surgeon in a few days.  The last one said there were too many issues going on for him to consider doing anything.

I am managing.  I am walking and working.  I can live with the pain, with the help of pain management. However my biggest fear is that the condition will worsen to paralysis if I do not have surgery.  Like the “annular tear” at L5-S1.  Will that lead to serious problems?

I have read almost every post on this site and am determined not to have surgery if possible.  On the other hand, if this will lead possibly to paralysis, my course of action is not well chosen.

Any and all input is welcome.  I will read and consider all points of view.  I enjoy immensely reading and gaining experience from the posters on this site.  Thanks to you all.

[femmy29]

Hi and welcome to the back pain community.

You do have significant degenerative disc and joint disease which I believe is contributing a lot to your symptoms.  I don't think anyone on the internet can advise you on whether or not you will become paralyzed from not having surgery.  Based on what we both know today, I think your approach is wise to consider surgery only after all conservative treatments have been exhausted.  The only other reason to have surgery is if there is a risk of losing feeling in one or both of your legs.  

What I recommend is that you see a physiatrist or spine orthopedic specialist at a teaching hospital.  Request a "nerve conduction study".  This study will shed some light on the extent of the nerve damage that you have and will help doctors determine if surgery is a urgent need or if continuing your current treatments is okay.

The spinal stenosis is indicated as severe on your MRI.  Yes this is definitely contributing a lot to your pain.  Spinal stenosis is also commonly known as narrowing of the spinal canal.  When the spinal canal is narrowed, the spinal wall begins to push up against the nerve roots, causing the pain that you are experiencing.  The facet arthrosis is likely causing the low back pain.  Injections can help with this type of pain.  Have you tried any injections like facet joint injections or epidural steroid injections?

Personally, I think taking just one dose of Percocet in the AM is not enough for the pain caused by the damage present on your MRI and the symptoms you are describing.  I am prescribed much more medicine than you and your MRI findings and symptoms are slightly worse than mines.  I recommend that you ask your doctor about Gabapentin.  The brand name is Neurontin.  It will help with the nerve pain you are experiencing down your hips and down your legs much more than the Percocet.  I think the percocet is still a key component as it is likely helping with the low back pain but Neurontin is much more effective at treating nerve pain.  You might also ask your doctor about adding a long acting opioid like Morphine ER that lasts 12 hours...then the percocet would be used for breakthrough pain.  

Hopefully I answered your questions, if not feel free to ask more if you have them.

Wishing you more days with less pain.

femmy

[Teachmath1953]

I enjoyed your thoughtful response.  In particular, I have tried epidurals with no effect.  I am also now taking Lyrica for nerve pain, but I am not sure how much longer I will be able to do that as it makes me nauseous and goofy.
I saw the orthopedic surgeon yesterday, and on the bright side he spent 30 minutes with me going over every detail of my MRI.  He actually seemed to recognize me as a person. I had typed a detailed chronology of all my prior care which he also recorded into the patient log he dictated along with my MRI interpretation.  My last orthopedic surgeon both visits spent 90 seconds with me, long enough to rudely say I was not in enough pain yet to consider surgery.
Now the down side.  Because of the anterolisthesis of L5 on S1, this Ortho wants to do a 3 level fusion.  He has ordered a CT scan.  When he was pointing out the foraminal narrowing on the films, I asked him about less invasive procedures, but he said he felt he would ultimately just have to do more surgery and the fusion at a later date.  So he really want to do the 3 level fusion.
I teach, so I plan to spend my summer losing weight and continuing my PT and swimming.  I do not want to begin a long and painful rehab from open back surgery if I can get out of it.  The Orthopedic surgeon yesterday felt strongly that I am not in immanent danger of paralysis, just my condition will continue to worsen.
I see the PM tomorrow and will see about adjusting the Meds.  He is not in favor of upping the narcotics because I teach, but in fact I tolerate them quite well.
I intend to read and reread your thoughtful reply--it really made my day.  It was helpful that I had spent time with my dictionary and also have spent time on these communities, so when the doctor was explaining things, I understood the language.  However enlightening his explanations were, at the end of the day, it is still the patient in charge, of their future, and being happy today.

[femmy29]

Hi There!

I am glad to read that my reply has been helpful to you and continues to be helpful.  That made my day!  :)

I have been told that I need a 2 level fusion and I am running from the surgeons like my life depends on it.  My best friend is married to a orthopedic surgeon and I asked for his advice and he told me not to do it as it is only 50% successful at relieving pain.  It is much more successful at stabilizing the spine to prevent further degeneration but many have come out of a fusion surgery with more pain than they had before surgery, partly due to the large amount of scar tissue from cutting open that large of an area where all sorts of branchial nerves are under the skin.  My Dad had a friend that committed suicide as there wasn't a pain medication out there that could touch the extensive nerve pain that he had after surgery.

The other issue is that more fusions could be in the cards for you just by getting one fusion surgery.  A 3 level fusion is going to put  A LOT of strain on the discs above the fusion and they will start to bulge and cause pain leading to the need to have that area fused.  My spine othopedic specialist told me this and he said further, that he could see me fused all the way up my spine when it is all said and done and that being fused all the way up would severly limit my range of motion.  You are not at risk for paralysis so I would 100% continue all conservative treatments until they are no longer effective and/or you can't take the pain anymore.  Any good surgeon will tell you this.  And even if you get to the point of seriously considering surgery, get a 2nd, 3rd, and even 4th opinion.  Make sure that there are more doctors that think a fusion is the way to go than not.  

Lyrica is very similar to Neurontin (Gabapentin) but some people experience less side effects on Gabapentin than Lyrica so consider Gabapentin if the side effects with Lyrica are intolerable.

I am on 180 mg of morphine equivalent a day (roughly) and I am a engineer that has a very complex job requiring complex presentations and I am able to perform well despite the medications I take for pain.  If you are tolerating the meds you are on now, you can most certainly tolerate slightly stronger (i.e., more effective) medications.  Doctors will slowly titrate you up to a therapeutic dose over a period of several weeks to minimize side effects and also to keep you from feeling completely out of it.

Please let us know how your appointment goes with PM.  Consider bringing with you a pain diary that charts your pain levels throughout the day given the pain medications taken and activity level.  This will be most advantageous to you at your appointment.  :)

femmy

[Teachmath1953]

Femmy,
The appointment with Pain Management went quite well.  The doctor is energetic, concerned about how I am doing in my job, and how my appointments with the Surgeons are going.  Above I had meant to write currently on Percoset 10 /325 four times daily.  The PM doctor upped it to Oxycodone 15mg four times daily.  He told me that the new script does not have Tylenol, so it will be easier on my liver.  The increase seems to help a lot, and the PM doctor said, "You seem like a responsible person, . . ." I was holding my breath because I have been reading all of the horror stories on this site, and others, about what can happen if they think you are a drug seeker when you are asking for an increase in medication.  I explained that the Lyrica did not work at all, and so we talked awhile about my reactions to that.  I then explained that I also could not tolerate SSRI s (I really do not want to try Ultram.  Celexa, Serzone, and Lexipro all drove me to thinking about suicide at a time in life when I was having psych problems due to the stress of grad school). And I read that Ultram acts also as an SSRI.  I just told the PM doctor that the current medication was not effective, and HE suggested upping the dosage.
Your technical discussion about how dangerous fusion surgeries are was very helpful! I personal hope that you never absolutely need this surgery either.  I consider my time spent with Orthopedic surgeons well spent, because of their detailed analysis of my MRI, and of course how they would "fix me."
I am currently working the program by Art Brownstein, MD, who wrote "Healing Back Pain Naturally.". I think that it is very insightful. Prior to this book, I had developed a pretty good PT exercise set, and had been using them daily.  However, I was afraid to walk any distance, because for me it can provoke incredible spasms.  With the books help, I am beginning to develop the level of understanding needed to go beyond that fear and walk and live again.  In my household it was helpful this morning to understand how stress plays a role in all of this, because my wife is going through a very stressfully time at work, and can become difficult and sullen. She launched an all out attack.  I did not retaliate, and though inwardly my back was still hurting and this situation was not making things better, I was able to defuse the situation.  Boy I have really gotten off topic!
If you have not read this marvelous book, I wholeheartedly recommend it. $10.00 at Amazon.com. One of its premises is no painkillers, but I believe it is ok to do a hybrid approach.  Some of his material granted is published elsewhere, but his personal story of being a physician and suffering at the hands of a back surgeon, and how he came back from Hell, is worthwhile reading.
I must thank you again for taking the time to communicate to me and others what Orthopedic Surgeons REALLY have to offer.