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I have nerve issues in the lumbar and my spine doc is in denial - advice?

38 year old male, 5'8  165 pounds. Fit and muscular. Warehouse worker for the past couple of years. Ridiculous amounts of lifting of 30 pound packages hundreds of times per day and also lifting them far above the head onto a nearly 7' shelf, which is outside of the safe lifting zone. Stacking the products down near floor level hundreds of times. Usually there was very little help, I'd come in to work regularly and find out that my coworker called out or didn't show up, etc. I hurt my back in November 2020 at work. My employer sent me to their local panel clinic from the list. Doc put me on >10lbs lifting restrictions and I had about 1.5 months total of physical therapy, TENS and cold laser therapy treatments with the on-site physical therapist. Didn't help. After a month of seeing no improvement, doc ordered a non-contrast MRI of the lumbar. Then I was discharged and the doc said that there was nothing else that she could do for me. In her notes, she randomly wrote that I failed to attend pain management, which was rather ridiculous given that my benefits were cut shortly after discharge and no referral or documentation reflects it. A couple of months after that, around March or April, I was going to see another spine doctor and he declined to see me after he saw the first doctor's notes that I failed to attend pain management. So that messed that up for me for another two months or so.

Got a worker's comp lawyer in February. It took until May to get a new treating doctor that the worker's comp insurance company kept promising. I finally got a spine doctor that my lawyer wanted me to see. He looked at my non-contrast MRI from 6 months prior and said he didn't see any nerves being pinched, but then doubled back and said that there 'could' be. I explained my symptoms and even with my legs, he acted like he "didn't know what was causing that".

His notes state:

"Thoracolumbar spine reveals mild tenderness to palpation. He has some mild sciatic list. Forward flexion extension is limited. Straight leg raise testing reproduces back and buttock pain bilaterally. No pain with range of motion of his hips. Good strength in all muscle groups from L1-S1. No sensory deficits. MRI scan is reviewed with lumbar spine advanced degenerative changes noted at L4-5 with disc space narrowing. Did not see any evidence of any nerve compression at that level. THe other levels are well-maintained. there is some edema in the endplates. Discussed treatment options with patient. Has not had improvement with physical therapy. Advanced changes noted at L4-5 represents exacerbation of an underlying degenerative condition through his work injury. I recommend bilateral L4-5 transforaminal injections. Continue his previous work restrictions."  My official diagnosis is Lumbar Radiculopathy. He basically said there's very little disc material between L4-5. It's almost completely worn away, yet no other discs show that kind of wear. No history of arthritis. There's some fluid around L5-S1, as well. Not sure which one the pain is coming from, unfortunately. He wants bilateral injections of L4-5.

My symptoms: I've had very severe, stabbing lumbar pain since November 2020. Bending forward, backwards, left or right causes severe lumbar pain that feels like a nerve is being crushed. I get up in the morning and usually can't stand up straight for a while after I get out of bed. I walk bent over forward about half of a foot. It hurts too much to walk straight. I have sciatica down both legs to the feet. On the outside of both legs, from below the knee down to the bottom of the calf muscles, my legs are numb-like. I've lost maybe 75% of sensitivity to the point where I could probably drag a knife down them and not feel it very much. I walk with an odd gait due to my lumbar pain. My legs feel weak, have tingling and burning intermittently down to the feet. Sometimes even lying down on my back at night makes both legs tingle or feel numb-like down to the feet. Whether on my back, stomach or sides, my back hurts at night. I developed random autonomic dysfunction symptoms 9 months after working that warehouse job. Never had them before. Rapid fluctuation in pulse rate and blood pressure by the second and 24/7 dizziness on certain days. Intermittent on other days. Could I be pinching an artery in certain positions in my lumbar?
Other symptoms that he also didn't want to talk about:  I've got some interesting bladder/bowel pain that feels like it is literally radiating through the center of body from my lumbar and into my abdomen and pelvis areas. I know that it is coming from the lumbar because even standing up straight, the pain in my lumbar spine gets worse and makes the front abdomen/pelvis area hurt worse based on symptoms. Certain postures make my blood pressure drop and my ears ring and it seems related to my lumbar because the pain increases and decreases based on posture. Carrying even 10 pounds standing straight up feels like I'm smashing a nerve in my lumbar.

Sometimes if I move the wrong way, the pain will get so severe in my lumbar that it will send me to the bathroom for a bowel movement. Sometimes very loose and other times a more normal one, but my bowel movements in general average 3-4 days. I've come across nerve maps linking the areas of the L4-5 to the bladder/bowels and also dermatome maps linking the leg numbness specifically in the areas of where my legs are numb. My legs are also considerably weak feeling some days.

But the question is...how do I GET the doctor to acknowledge this? I have some transforaminal injections coming up in just a few days from today. I'm absolutely puzzled that he doesn't seem to link the nerves of the back to my symptoms simply because he doesn't "see" nerve impingement.

Trying to get another contrast MRI, discogram or other means to look more closely at nerve impingement might be nearly impossible given the insurance company. They me probably $7K in back pay to February at this point and should be paying ongoing benefits. Have struggled to pay bills since February. Any advice for something that might help convince my doc? The Lumbar Radiculopathy is, of course, typically a pinched nerve. But since he doesn't "see" it on the MRI, he's hesitant. Yet he scheduled injections at the same time. He also talked about potential surgery in the future if the injections don't work. Which, to my understanding, they are not permanent and can last at most 1-2 months. Not sure what type of surgery he would want to do.
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Avatar universal
I'm not sure any MRI will show a pinched nerve.  They infer that from your symptoms.  MRI's show soft tissue, X-rays show the hard tissue to see if it's osteo arthritis.  Disc problems are very hard to verify as being the cause of anything, because all humans show disc deterioration as we age.  More often problems are muscular, not due to the disc.  But in your case, you are definitely showing nerve problems with the sciatica, but the problem bending over isn't a nerve problem, it's a muscular problem.  I know all this because I've got a lot of problems, too, and I've been down this road.  You might very well have multiple problems, some of which don't show up on MRIs, such as aggravating your periformis muscles.  These are near your buttocks and are part of the hip and the sciatic nerve often goes right over them and if inflamed hits them.  I've had it, apparently, because it doesn't show up on any diagnostic imagery.  If you showed a significant disc injury, the treatment, I think, would be surgery, whereas injections are usually cortisone and might help but would usually be temporary.  It's possible the PT you got wasn't very good, for example, cold laser is a myth, it has no evidence backing it up as doing anything.  I can't tell you what you have, but you need to see an orthopedic surgeon who will tell you if you need surgery.  If your imaging doesn't show anything significant enough for that, as it apparently didn't they will always send you to PT.  Injections are when it can't be fixed.  You have to do something quickly, because the way you're walking will really mess you up.  Again, can't tell you what's wrong, can only tell you the injections might help you stand up straight for awhile and might give the PT a chance to work, but you'll need to try a different place for it I think.  It can take a long time to rehab an injury, and if you stopped doing the PT, it won't work.  But it also seldom fixes anything,, it usually just stops you from doing the thing that hurt you and then hopefully your body heals itself in the meantime.  It might be you do need surgery, but docs are conservative about it because it doesn't always work.  I think the surgery is fusion, which basically takes that disc away and will limit your mobility but get rid of the offending pinch.  If it works.  If you like your docs, you gotta do what they say.  If you don't, find better docs.  If money is a problem, in this world, you're screwed.  Peace.
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