Question
I was in a car accident on 11/21/06.  The x ray was unremarkable.  My chiropractor treated me with TENS electrotherapy, spinal manipulative therapy, and decompressive traction.  In January, 2007, I received a MRI.  This showed L4-L5 right-sided extraforminal disc herniation, exhibiting foraminal encroachment and effacement of the L4 right exiting nerve.  Coexisting degenerative facet arthropathy produces bilateral foraminal stenosis of moderate severity, broad-based noncompressive disc bulge at L3-L4 accompanied by mild discogenic spondylosis, bilateral facet capsulosnovitis at L4-L5 and L5-S1, and central dis herniation involving T-4-T-5, relulting in ventral cord effacement.
I continued with chiropractic treatment until June 11,2007.  I received physical therapy from June 14th until August 8th.  This didn抰 help with the pan, so I started back with chiropractic treatment in September, 2007.  I went to see a doctor at the Burlington Spinal Clinic on October 18th.  I was told that my problem was 搉ormal wear and tear?and he didn抰 recommend any treatment!  I was sent to a doctor for injections on Oct. 22 and Nov. 14, 2007.  He said my MRI wasn抰 very clear.  His impression was: degenerative disc disease of lumbar and thoracic, lumbago, facet joint S-M.  I was given lumbar facet joint injections and trigger point injections in the T-4-5 area.  This only took the edge off the pain in the thoracic area and didn抰 help the lower back pain.  
I never had pain before the accident and have had pain every day since.  The pain in my mid back at times feels like I抦 being stabbed from my back through my chest.  The pain in my lower back extends down my right buttocks.  The pain is mild at times and increases with prolong sitting, standing, and other various activities.
The two doctors made me feel like the pain was all in my head or was just part of the aging process.  I was frustrated because I know my pain is real and I never had pain before the accident.  I asked my chiropractor to send me for another MRI.  On January 9, 2008, this revealed:  Central disc protrusion or focal disc herniation involving t4-T5, resulting in ventral cord effacement with resultant cord flattening deformity, T6-T7 broad-based central des protrusion, resulting in ventral cord effacement, left eccentric noncompressive disc protrusion at T7-T-8, multisegmental discogenic spondylosis of mild severity, accompanied by vertebral body osteophytosis, right dis protrusion involving L-4-5, exhibiting foraminal encroachment and effacement of the right L-4 exiting nerve, coexisting right eccentric annual tear is also present, broad-based concentric noncompressive disc bulging at L3-4 in the presence of mild discogenic spondylosis, mid to lower lumbar degenerative facet arthroathy, resulting in mild to moderate severity forminal stenosis at L-5-S1, mild bilateral facet joint capsulosynovitis at L-4-5 and L5-S1.
I抦 not sure what this means, could you explain.  What do you suggest for treatment?  I know there is danger in surgery, but is there a danger in not having the surgery?  If you do suggest surgery, where should I go?  I live in Northern NY梟ear the Vermont/Canadian Border.
Sorry this is so long.  Thank you for your time.


Answer
Dear Darlene.

First, sorry it has taken me a week to respond, but I have been very ill with a bronchial infection.  Your MRI results:  the disk bulges in the T4/T5/T6/T7 (mid back) areas are pressing on the spinal cord which can result in numerous problems with nerve transmission from the brain to the organs, muscles etc...The front part of the spinal cord houses the descending information from the brain out to the tissues, and that is the part that is being crowded.  You also have a multitude of degenerative changes in that area which means that you have ongoing arthritic processes which can result in spurs, pressure on the nerve roots, chronic inflammation, and obvious pain.

The low back area is significantly degenerated as well.  You have multiple disk bulges, however the L4 L5 area is the worst, and is pressing on the right nerve root in that area.  The L4 nerve root affects the muscles of the thigh (quadriceps) which extend the leg, and the pain patterns for this nerve extend down the front of the lower leg to the top of the foot.  You likely have symptoms along that course on the right side.  However, there is an additional problem with the joint spaces just below that level, again due to degeneration.  This can be a significant source of localized low back pain across the belt line...often a deep sore area with sharp pain while bending backward or to the side as the joints become compressed.  Lastly in this area the holes in which the nerve roots exit the spine are reduced in size which will irritate/compress/inflame the nerve root.  The pain patterns from this nerve root extend down the lower legs to the foot, and you may have difficulty walking on your heals or toes due to compression.  

For a better understanding of the pain patterns of the nerve roots affected, check out the glossary section of my website and look up the term dermatome for a full description with a link for illustrations of the pain patterns.  Now, in additional to dermatome pain regions, there is also something called referred pain which does not follow the nerve root patterns.  This is called sclerotogenous pain, and is often broad, diffuse and chronic.  It stems form the soft tissue structures such as ligaments, the disk, and the joint capsules.  I would suggest that you also look up the word sclerotome in the glossary section as well.

Unfortunately, with the amount of degeneration you have present, continues chiropractic care will probably have only marginal benefits in reducing pain and increasing function.  I would expect with your imaging, and history of care in relation to the crash that you should seek a surgical consult.  Realize that chiropractic care cannot get rid of the degeneration, and if the previous decompression did not help the disk pain, then you are a surgical candidate at this time.  I would recommend that you continue with the chiropractic while adding in some functional stretching and rehab exercise, however, I think you will ultimately need surgical intervention to eliminate the anatomical problems:  bulging disk material and bone spurs.  Techniques to research are:  diskectomy, foraminotomy, and nucleoplasty.  These surgical procedures have become less invasive over the last few years, and require less insult to the tissues.  Also laminectomy may be a procedure that is mentioned.  this would be the most invasive, but many patients do well after the pressure is released from around the disk and nerve root with this procedure.

Good luck Darlene.

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