Question
My doctor says I have a torn disc and a protrusion and I am a ER nurse and he said this will permanently disable me.  I have minimal dull ache down left leg and occassional spasm in the buttock however reading my MRI results: L5S1 small central protrusion is present but does not caus significant central canal or foraminal stenosis and L4-5 slight retrolisthesis and a minimal disc bulge result in minimal narrowing of the left and mild to mod narrowing of the right neural foramen does not sound like a tear to me.  What can I do to not end my career?  He suggest spinal epidural injections for the pain but what can I do to not end my career?  He says I can't lift more than 20 lbs.  I'm not sure I haven't had this for a while as my whole family has bulging discs. I don't want to end my career what do you suggest as my options.  I have only been to the spine dr once. Should I see a chiropractor or a ortho doctor or a physical therapist or am I just doomed?  Please can you give your opiniion?

Answer
Dear Renee,

First of all you are not doomed...what the heck is that?  Can't believe your doctor told you that you would be permanently disabled forever.  Just because he cannot ascertain how to treat your injury does not mean that he should blindly send you for pain management procedures.  Yes you have a broad based disc bulge which is evidenced by some level of encroachment of the neuroforamen bilaterally. But does your pain transmission follow the known dermatomes of the L4/L5 and L5/S1 nerve roots (down the outside of the lateral lower leg and into the foot)? If not then compression is not occurring.  If you have an annular tear, your pain is probably more sclerotogenous in nature (referred pain)..more broad based, dull an diffuse rather than shooting.

However, the bulge is not pressing on the thecal sac or cord, and central stenosis is not present, which is a good thing.  Now, I do agree with your doctor that you should limit lifting to under 20 lbs until you have completed rehab, and you should also limit repetitive bending and twisting...this will make the problem worse.  Also, I would suggest that you have another radiologist read the films for a second opinion, and ask about the quantification of the bulge...is it a 3mm or a 5mm.  Over 5mm should be considered a herniation and will be more difficult to treat.

First, I would caution you in the application of pain management.  I actually shared an office with a board certified pain management anesthesiologist for 12 months and I am intimately aware of the procedures utilized.  Epidural injections will do nothing to heal the disc or stabilize the spine. It will only help to centrally control the pain so that you do not feel it.  This leads to the lack of protection of the spine and is often the direct result of further injury.  The pain is there to protect you...if you have no discomfort, you will continue to perform the activities that have resulted in the problem.  Not to mention if the the neurological pain signals (nociception) are not allowed to get processed in the brain, then neither will the information on pressure, stretch, movement, etc.. (mechanoreception).  Also vitally important is the proprioceptive signals (information on body position and awareness).  You cannot effectively rehab tissue without correct proprioceptive impulses to the brain, and mechanoreceptive signals actually reduce nociception.  I encourage you to research more about these neurological receptors and the spinal tracts that carry the information to the higher centers of the brain for processing...it is very important for effective rehab.

The second thing you need to do is arm yourself with as much information about disc injuries and the effective treatment of them.  Do not ask your colleagues for information on this...they know the medical model, not the conservative care model, do your own research.  Familiarize yourself with the terminology utilized as well as the anatomy and physiology.  I am more than happy to help you with this:  send me an e-mail through my website, and I will send you some Word and PDF documents that cannot be attached to this allexperts response.

Third, I would suggest that you at least schedule a consultation with a chiropractic physician...we treat lumbar and cervical disk problems all the time conservatively, and most do not need pain management or surgery.  Make sure you find one who has a dedicated rehabilitation room.  This will ensure that they actually do rehab on a daily basis.  Do not go to a chiropractor who only adjusts the spine...you will need concurrent rehab to stabilize the spine. Also check to see if the office offers cox flexion/distraction technique or spinal decompression.  Both are effective in managing lumbar disc problems.  If they offer spinal decompression make sure they do not charge too much for it...$2500 to $3000 for the entire program to include the rehab portion is a fair price...some doctors charge over $5000 which is ridiculous.

Please ask the doctor to show you a written account of his post-doctoral coursework or certifications.  Most doctors are proud of their training and accomplishments...so if they do not want to do this, ask why?...what are they hiding?...have they not completed any advanced coursework? Chiropractic physicians certified in sports injury, rehabilitation, or orthopedics often have the best knowledge.

Specifically the intrinsic muscle of the spine which provide stability need to be addressed.  Focus should be on the multifidus, rotatores, and intertransversale musculature along the spine. Do not perform traditional sit-up or abdominal work and never stretch the low back in a standing position (only while seated on the ground).  Why...because both exercises increase the pressure on the disc significantly and will result in more injury.  If you want to do crunches, which are helpful for spinal stability, the bottom tip of the scapula (shoulder blade) should not lift off the ground.  This allows for abdominal strengthening without low back pressure increases or low back muscular firing.  

**Good book to read... (Low Back Disorders:  Evidence-Based Prevention and Rehabilitation) by Stuart McGill.

Listen Renee, I am not trying to bash what your doctor has told you thus far, but due diligence requires that you question his answers.  I see this all the time, and often get patients in my clinic after pain management has not helped...they are much harder to work with at that time.  Do not give up hope, only about 10 of my disc patients need to be referred out for surgical correction, most I can help and they function well.

Don't forget to e-mail me...you can contact me personally through my websites. I will send you more information on disk anatomy/pathology, sclerotogenous pain referral, and how chiropractic effects the peripheral and central neurology, and reduces pain.  Hopefully this will not only serve you well, but the lives of the patients you treat who will experience similar problems. Good luck!!

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net