Adam Rufa - 5/12/2006

Question
PRE-OPERATIVE HISTORY

                  I am 46 years old male and suffering from Low back pain along with left sciatica since September 2001, while the pain was constant in nature and radiates towards buttock/left leg and became worst on sitting, standing and getting out of bed, as such there was no neurological deficit. The SLR of Rt leg & Lt leg was 70 &50 degrees respectively. The conservative treatment including NSAID's and physiotherapy received but got no relief.

POST-OPERATIVE HISTORY

Due to failure of conservative treatment and having more than three years of back pain history I entered into lumbar surgery in February 2005 on the advice of concerned Neuro surgeon, because the result of my MRI showed multilevel disc degeneration & at the Level of L4-5 there was mild central posterior disc protrusion causing pressure on ventral surface of thecal sac. The surgeon used the technique of Fenestration and removed the disc at L4-5 without doing a fusion, but unfortunately the LEG/LOW BACK PAIN couldn't be subsided till now & intensity of pain is same as pre-op, beside having postoperative physiotherapy. Now the pain is worsened by sitting, standing or walking for a long period of time. Left leg stiffness and back discomfort also persists.

                    However I repeated my MRI scan with contrast along with X-rays of L/spine during last week and the reports of the same are reproducing below for your kind perusal.

MRI LUMBOSACRAL SPINE DONE WITHOUT AND AFTER CONTRAST ENHANCEMENT WITH GADOLINIUML:

.*There is disc degeneration in the lumbar spine at L2/3 and L4/5 with narrowing of disc space at L4/5.

* Previously noted diffuse disc herniation at L4/5 appears resected.Now there is disc bulging with facet joint hypertrophy at L4/5 causing slight pressure over thecal sac and left neural foramina.

* Postoperative changes are noted at the level of L4/5 in the posterior paraspinal region along with enhancing granulation tissue within the thecal sac and posteriorly at this level.

* Disc bulging is noted at L3/4 and L5/S1.

* The spinal cord shows no abnormal signal.

* The vertebral bodies show no evidence of abnormal signal to indicate bone        marrow replacement.

* There is no spinal stenosis.

* MR myelogram shows no obstruction to flow of CSF.

CONCLUSION:-

* Previously noted diffuse disc herniation at L4/5 appears resected.Now there is disc bulging at this level with facet joint hypertrophy causing slight narrowing of left neural foramina.

*There is also disc bulging at L3/4 and L5/S1.

*There is no spinal stenosis.

* MR myelogram shows no obstruction to flow of CSF.

LUMBOSACRAL SPINE (AP & LAT):--

 * Loss of normal lumbar lordosis.

* Osteophytes are seen along the margins of vertebral bodies.

* Partial sacralization of L5 vertebra is seen.

* Inter-vertebral disc spaces appear normal.

* No fracture or dislocation is seen.

* No bony erosion is seen.

* Paravertebral soft tissue shadows appear normal.

* S.I joints appear normal.

IMPRESSION:-

* Loss of normal lumbar lordosis梔ue to muscle spasm.

* Osteoarthritic changes seen in lumbar spine.

* Partial sacralization of L5 vertebra

QUESTION
I don't want to jump again into surgery as the result of previous surgery made me quite embarrassed/frustrated, What option I have at this stage to resolve my problem,in the light of above mentioned history,please?  

Answer
Unfortunately there is no easy answer for your question. MRI results are only of minimal value when not correlated with a physical exam. An MRI can only give a picture of static non-weight bearing structure witch does not always tell you the cause of pain. Treatment for this type of problem is often trial and error and conservative treatment does not always work (either does surgical).

Treatments like spinal stabilization with an emphasis on the transversus and multifidi can sometimes help in more chronic cases. Mobilization and manipulation appear to be less effective in more chronic cases but they can sometimes help.

I would advise that you look into pain theory and learn how the nerves and central nervous system can play a large role in the perpetuation of pain. I would suggest that you read the book "Explain Pain" by David Butler and Loramir Mosley. You can get it on there web site  (http://noigroup.com/booklist.html).

Good luck

Adam