Question
Hello there....
First of all let me thank you in advance for answering my question. I have been searching for much needed clarification, and have failed to do so: with my own doctor!
Her's my story:
I am 35 years old and have worked as a Certified Nursing Assistant in geriatrics ( nursing home) for nearly 17 years consecutively. Recently, I had somehow managed to hurt my back at work ( first time ever); yet can't pinpoint a certatin time in which it occurred. Prior to that injury, I had worked many 16 hour shifts, short-staffed ( ofcourse)and lifted, turned, boosted, etc. many heavy people by myself. One day I arrived at work and 2 hours into my shift I began to feel a progressing burning and stiff feeling in my lower back. 2 hours later it began to shoot down my leg; soon after I had difficulty walking, bedning, stooping, kneeling, and lifting.
Anyway....
I will disclose the MRI results shortly. My major question is this: how soon after a herniated disc or an annular tear occurs do you begin to be symptomatic? Is this something that may have been "dormant" in some way, and just now deicides to show its "ugly" face? Also, what are my chances of full recovery, and for returning to a heavy lifting job such as the one that I have? I a currently on a 10 lb. weight limit, no bending, no twisting, change positions frequently,6 hour days, break frequently work release. The problem with that is that I can't make it in to work most days that I am scheduled due to the pain factor and the inability to walk and/or stand. yet, my doctor refuses to take me off work. He has also begun to wean me off of Percocet and on ibuprofen only even though the pain is unbearable at times.
These are my symptoms: chronic pain in lower back, burning, stabbing, stiff kind of pain; chronically on a pain scale of 5-6 ( on a good day) the pain is an 8-10 at other times. The pain at times radiates down my right leg, at times it burns only in the lateral side of my right calf. Pain worsens upon standing, sitting, bending, and excessive walking.My toes( right foot) are chronically numb, and at times my right calf and foot is as well. Driving with the right foot sends a burning sensation up the back of my thigh and extends to the lower back region.I also have been exeriencing chronic muscle twitching in my lower left calf, as well as severe and intermittent "charley-horses" in the entire left leg-- since the injury has occcurred.
Ok, here's what the MRI report said:
IMPRESSION:
small right extraforaminal protrusion with evidence of annular tear at L4-5; broad based disc bulge with small central/left paracentral protrusion at L5-S1 with minimal effacement of the anterior aspect of the thecal sac ( what does this mean???) ; mild foraminal narrowing is seen at L5-S1 on the left side. FINDINGS:
- evidence of disc dessication at L4-5 and L5-S1
- mild discogenic endplate changes are seen at the S1 level
- @ L5-S1 there is a broad based disc bulge with a small central/left paracentral disc protrusion. There is mild foraminal narrowing on the left; no abnormal narrowing on the right.
- at L4-5 there is a broad based disc bulge. There is a small right extraforaminal protrusion with a focus of hyperintense T2 signal consistent with small anular tear.

Could you please explain what all this means, and if these findings are consistent with my symptoms? I have performed many internet searches and have found contradicting information. Are my "protrusions"/broad based disc bulges actually herniations? My doctor states that they are herniated, yet the MRI report is stating that they are bulges. Mainly, if you could just explain the anatomical location of these protrusions to me, as well as the foraminal narrowing; any clarification you could give to help me understand more would be GREATLY appreciated! Once again, thank you for your efforts, knowledge, and your time!
~robyn


Answer
Hello, Robyn,

First, I'll say that disc injuries are not my specialty.  However, I can say some things that may be helpful.

The term, "extraforaminal protrusion," and "effacement of the thecal sac" suggest more than a herniation or disc bulge -- it suggests extrusion of disc material into the space where the nerve root exits.  The different use of language by different practitioners makes interpretation of their comments uncertain.

However, the symptoms strongly suggest impingement of nerve roots by extruded disc material, giving rise to sciatica and the motor artifacts (twitching and charleyhorses) you describe.

Regardless, disc bulges commonly result from paraspinal muscular contractions formed through emotional stress (long hours in a short-staffed situation -- see somatics.com/page4.htm, BACK PAIN, for a discussion of the neuromuscular Landau Reaction) and repetitive lifting actions; annular tears result commonly from "lift and twist" injuries.  It seems to me that this work-related injury has been a long time in coming.  I wonder why surgery (to remove the extruded disc material) hasn't been recommended.  That your physician is trying to wean you off of pain meds and is unavailable to discuss your condition with you suggests to me that you should change physicians, or at least get a second opinion.

As to the time between injury and the appearance of symptoms, with disc material extrusion, I would expect symptoms to appear immediately, upon occurrence of nerve root impingement.

best,
Lawrence Gold