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Blown disc in lower right back

Posted by Josh on July 26, 1999 at 09:54:08
I have been having pain in my lower right back and down my right leg resulting from a fall at work.I have had a ct and mri done and all checked out ok.I am waiting to take a emg which where the office cant get me in for 2 weeks.My employer is pushing me towards chiropractic and physical therepy wanting me to start now before I get the emg done.I am in severe pain and discomfort and have been for 3 weeks now but not knowing the extent of my injury would it be wise to seek chiropractic treatment.could this worsen my condition?

Posted by CCF MD GS on July 26, 1999 at 12:54:50
Thanks for the question. We are usually not prone as a group to refer patients for chiropractic manipulation but the practice is certainly widespread. I think that physical therapy is a good idea and may be helpful. The fact that the MRI scans are normal is good. If you see a chiro I would avoid maipulation and just do stretching and soft tissue work. As you know the optimal treatment for low back pain is very controversial but I think most of us would avoid surgery if other options were available. Good luck
This information is provided for general medical education purposes only. Plaese consult your doctor regarding diagnostic and treatment options.

Posted by Laura B on July 26, 1999 at 22:42:26
What would your recommended course of action be for this problem?
I am 40 years old, and currently do not want to live to be 41.  Three years ago, after an MRI I was told everything was fine, but that I would live in pain always.  I am having severe pain that I can no longer tolerate, and the Dr. ordered an MRI.  I will undoubtedly seek a second opinion after I speak with him, and want to work with compassionate doctors that don't dismiss their patients with words of "there is nothing wrong and nothing I can do for you".   I do not want to become an unproductive member of society.  I live in Illinois and can make it to your facility for a second opinion.  Additionally, I am having left leg pain, which I did not mention to the doctor.  
Here is the interpretation from the MRI from 1 week ago.
Clinical Data: Prior disectomy with C6-7 fusion.  Neck pain with radiation to left arm.  Evaluate for disk herniation/nerve encroachment.
Again noted are the changes of diskectomy and anterior fusion performed at C5-6 and C6-7 with obliteration of intervertebral disk space signal at these levels.  There is reversal of cervical lordosis centered at C6.  Because of the slight kyphotic curvature, there is encroachment upon the ventral thecal sac, but the posterior subarachnoid space is patent and there is no frank cord compression.  There is some subtle increased signal within the cord at C5 - C7 levels, some of which may be artifact, but a component of myelomalacia is possible.  As mentioned previously, there has been anterior cervical fusion at C5-6 and C6-7.  There is susceptibility artifact emanating from the C6-7 disk which may represent some metallic fragments related to surgical drilling.  The C6 and C7 foramina are widely patent.  There may be a very minimal osteophytic spur at the C6-7 level, along the right paramedian margin.  A small amount of material is situated ventrally and mesially which encroaches minimally upon the ventral thecal sac.  There is mild flattening of the ventral surface of the cord at the C5-6 and C6-7 levels, but as mentioned previously, no frank cord compression.  Focal area of increased T1 signal within the C6 vertebral bodies consistent with hemangioma.  There is susceptibility artifact emanating from the ventral aspect of C7 - T1 junction, on the right, consistent with metallic artifact.
There is focal enhancement within the posterior mesial annulus at the C4-5 level.  There is small central disk prolapse at this level and the findings are consistent with radial tear with ingrowth of granulation tissue.  These findings were present on the prior study.  The neural foramina are widely patent bilaterally at this level.
There is abnormality involving the left C3-4 facet joint which appears widened with increased fluid.  The soft tissues around the facet joint appear thickened and enhance.  However, there is no edema within the paraspinous musculature and I think it is unlikely that these findings are infectious in etiology.  However, there is some encroachment upon the left C4 foramen.  These findings are not well visualized on the prior study.
1. Post surgical changes C5-6 and C6-7 with anterior cervical fusion.  There is accentuated kyphosis at this level with flattening of the ventral surface of the cord, but no frank cord compression.  Subtle signal changes within the cord are of uncertain significance, but a component of myelomalacia is possible.
2. Small central disc prolapse C4-5 with enhancement of the posterior mesial annulus consistent with a radial tear and ingrowth of granulation tissue.  Not changed from prior exam 3/96. (The doctor failed to tell me this).
3. Left C3-4 facet arthropathy and possibly a component of synovitis. While this may be degenerative in etiology, other etiologies such as gout or Crystalline Deposition Diseases (CPPD) could give a similar appearance.  Infectious etiology is felt unlikely, but not excluded.  There is a component of soft tissue encroachment upon the left C4 foramen.  Further information may be gained by correlation with CT through this area.  
Thank you for your time.
Posted by CCF MD mdf on July 27, 1999 at 08:50:38
Of course, we can't give medical advice here. However, you are welcome to call our appointment line at 800 223-2273. Tell them you want an appointment in the Spine Center (you'll be transferred by the operator). Judging from the MRI report and your symptoms, that is the appropriate specialty group to see.
I agree that if you are in such pain, it is inappropriate to say "there is nothing wrong." There may not be anything surgically correctible, and there may be nothing that threatens the integrity of the spinal cord or nerve roots, but there is certainly something wrong if you are hurting. If you are examined by a neurologist who can confidently say that there is no damage or at least no progression of damage, then treatment can focus on the symptoms themselves (pain, etc). The key is to get to the right group to address the problem. My experience is that this sort of problem requires patience and persistence as well as some creativity.
I hope this helps. CCF MD mdf.
Posted by chris smith on July 27, 1999 at 10:32:11
I'm posting as a followup to this question because of the reference to a facet joint abnormality. I posted about 6 weeks ago describing abdominal pain I've had for 2 years and the possibility of it being caused by a back problem. In May I developed right back and hip pain and an MRI was ordered. When I posted I was still waiting for results of the MRI. I was told that there are two bulging discs in the lumbar area, plus two facet joints are hypertrophied. I was referred to a pain clinic where I had an evaluation and was told these findings *could* be responsible for my pain or they could be coincidental. I also have tingling/prickly feelings in the soles of my feet. I understand that many people have bulging discs that cause no problems. Are bulging discs easier to herniate and if so, should one need to limit the types of physical activity such as high impact activities?  What would cause facet joints to hypertrophy and could this be responsbible for my symptoms? The doctor said it appeared that the body is laying down calcium. Why would it do this?  I started on celebrex and by one week I felt almost normal. I went off it for 2 days and the symptoms (the abdominal, back and hip pain) returned.Does this give any clues? I am scheduled for a PT evaluation. The pain clinic doctor also recommended a few manipulation sessions so I found this post's question about whether or not manipulations would help or hurt. Thank you for your opinion.          

Posted by CCF Neuro[P] MD, RPS on July 31, 1999 at 08:31:26
Dear Chris Smith:
Changes in the intervertebral discs and ligaments is a consequence of aging and perhaps in systemic diseases depending on the person and situation.  At the Cleveland Clinic we found that in routine MRI of the spine in people not complaining of back pain that over 20% had buldges.  As we age deposition of collagen and elastin occur as the cartilagaenous end plate becomes less vascular.  The dehydrated disc thins out and becomes more fragile.  This is more pronounced in women as they have more loss in Calcium.  As people approach the 50's it has been estimated by studies showing 70% of people have buldging discs.  The shrinkage of the disc also alters the alignment of the articular facets and vertebral bodies, leading to hypertrophy of the articular facets and may result in facet arthropathy and spur formation.  
Part of the remodeling process involves the inflammatory response, and that is likely why the cox-2 inhibitor has been helping you.  Or it may also be confounded by a system disease you might have such as osteoarthritis (if you have a system disease).  
It seems to be evident that if you begin to do heavy weight lifting with bulging discs, your changes of herniation goes way up.  Moderation with correct anatomical form (using your legs to lift) etc would reduce the chances.  I would make sure that I do not have increased pressure on my back due to bad use of the back.  Just be careful and not do things that are not smart, i.e. decide to become a furniture mover.
I hope this helps you.
CCF Neuro MD

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