Question
Here is my story:

Back on November of '06, I was lifting a Christmas tree in my home and felt sudden, sharp, debilitating pain in my lower back.  It was so painful I had difficulty straightening up.  I took three days off of work for complete bedrest, lots of advil, and by the fourth day I seemed better.  I never saw an MD.

The pain never really completely went away from that injury, but it was manageable.  

Around 4 months later, I still hadn't gotten 100% better, I went to see my primary care physician, and told him that I suffered from "moderate pain in the lower back, mostly on the left side, worse while sitting, better while standing or laying down.  I also have tingling and numbness in my left leg while sitting (sciatica)"

My PCP recommended an MRI.  I got the MRI of my lumbar region and it showed a large (8mm) extruded disk at the L4-L5 level.  My PCP referred me to an Osteopathic surgeon.  I had a consult with the osteopath at the beginning of march of 07.

The osteopath said we could try surgery or physical therapy.  Since the pain was not debilitating anymore, and really didn't interfere with my life, I opted for physical therapy.

The physical therapy was fine for several weeks; I thought I was experiencing minor improvements, when on march 27th of this year I had a sudden onset of a very troubling and traumatic symptom:  Out of nowhere I suddenly had nearly continuous urinary frequency.  The strong, persistant urge to urinate (even with an empty bladder) plagued me during every minute of every waking hour.  I couldn't eat. I couldn't concentrate.  It was torture.  It just came on one day and didn't stop.

I saw a urologist and he tested my urine and said it was clean: no infections.  He gave me some Detrol LA which did not help at all.  My urologist suspected that this urinary frequency was relating to my back injury.  Since I didn't have any pain or noctural frequency problems, he ruled out Interstitial Cystitus.

I consulted with my Osteopath and he too agreed this could be relating to some sort of pinched or pressed nerve that leads to the bladder.  We scheduled disk surgery ASAP.  On April 2nd, I had the disk surgery...I can't remember the procedure but the surgeon said he basically "removed the part of the disk that had become extruded" but he did not touch the disk.  He also noted that my L4-L5 disk appeared to be degenerating.  He said I am suffering from "degenerative disk disease" there and that led to the extruded disk.

The good news is that the back pain and leg tingling vanished...but the bad news is that the urinary frequency did NOT.  Since then, I have seen four urologists, none of them can explain why I have urinary frequency. All of them think this is related to my back.  My osteopath DIDN'T think it was related to my back because he said after he removed the pressure from the extrusion everything looked fine.  

My post-surgery physical therapist thinks it could be Pelvic Floor Dysfunction brought on my the back injury.  My acupuncturist thinks it's a pinched nerve in my back at the L4-L5 level.

Any ideas on what this could be?  Could an L4-L5 injury affect nerves to the bladder?  If so, how does one treat that (especially if I've already had surgery to fix the extruded disk problem)?  Should I see a neurologist?  I have read that sciatica can affect the detrusor muscle in the bladder and cause urinary frequency.  Vesicare did not help me at all, and Elmiron (that I'm taking in case it IS interstitial cystitis) does not really help either.

Answer
Hi Mark,

The best way to approach this is by elimination. Since most disc herniations don't require surgery or physical therapy, I would start with flexion/distraction. In short order this will either confirm or eliminate the pinched nerve theory.

There are three areas of the central nervous system (CNS) that control bladder function:  the sacral micturition center, the pontine micturition center, and the cerebral cortex.  The sacral micturition center is located in the spinal cord at the sacral (S2-S4) levels and is responsible for bladder contraction.  The pontine micturition center is located in the brainstem (pons) and appears to play a role in coordinating relaxation of the external sphincter with bladder contractions.  The cerebral cortex plays inhibits the an inhibitory role in relation to the sacral micturition center.

Bladder Innervation
Sympathetic nerve fibers travel from the spinal cord (levels T11-L2) to the bladder.  These fibers maintain relaxation of the bladder for urine storage.

Parasympathetic nerve impulses travel from sacral spinal cord levels (S2-S4) to the bladder wall where they produce bladder contraction and sphincter relaxation to allow voiding.



In addition to the internal sphincter, there is also an external urethral sphincter that is under voluntary control and is innervated by nerves originating in the sacral spinal cord (S2-S4).  This sphincter normally contracts in response to coughing, Valsalva maneuver, or when a person actively tries to prevent the flow of urine.

Since flexion/distraction decompresses the entire spine, I would have the physician start in these areas.


Flexion-Distraction Therapy - What is it?


Flexion-Distraction, (F/D) is a gentle, chiropractic treatment procedure utilized for back and neck pain. Flexion-Distraction is a safe alternative to back surgery for those 95% of patients whose conditions do not demand surgical intervention. The doctor is in control of the treatment movements at all times.

Flexion-Distraction is utilized for many conditions such as:

Failed Back surgical Syndromes
Disc Herniation/Ruptured Disc / Bulging Disc / Herniated Disc
Sciatica / Leg pain
"Whiplash" injuries
Stenosis
Arm Pain
Neck Pain
Failed course of Steroid Injections
Chemical Radiculitis
Spondylolisthesis
Headache
Transitional segment
Many more conditions?
How does Flexion-Distraction Work?

For Disc related conditions:

Increases the intervertebral disc height to remove annular tension on the annular fibers and nerve by making more room and improving circulation.
Allows the nucleus pulposus, the center of the disc, to assume its central position within the annular fibers and relieves irritation of the spinal nerve.
Restores vertebral joints to their physiological relationships of motion.
Improves posture and locomotion while relieving pain, improving body functions, and creating a state of well-being.
For Non-Disc related conditions:

Patients with other conditions causing back pain (facet syndrome, spondylolisthesis, sprain/strain, scoliosis, transitional vertebra, sacroiliac restrictions and misalignment, certain types of spinal stenosis), Flexion/Distraction provides all of the above benefits plus the ability to place the spinal joints into normal, painless movements so as to restore spinal motion without pain:

The posterior disc space increases in height.
F/D decreases disc protrusion and reduces stenosis.
Flexion stretches the ligamentum flavum to reduce stenosis.
Flexion opens the vertebral canal by 2 mm (16%) or 3.5 to 6mm more than extension.
Flexion increases metabolite transport into the disc.
Flexion opens the apophyseal joints and reduces posterior disc stress
The nucleus pulposus does not move on flexion. Intradiscal pressure drops under distraction to below 100mm Hg. On extension the nucleus or annulus is seen to protrude posterior into the vertebral canal.
Intervertebral foraminal openings enlarge giving patency to the nerve.

Reference: Cox JM, Feller JA, Cox-Cid JA: Topics in clinical Chiropractic 1996; 3(3):45


By going to the website below, you can find physicians that are certified in your area. If this is unobtainable in your region, I can do a more in depth search. Let me know if you need help.

http://www.coxtechnic.com/homepage.asp

Good Luck,
Dr. Timothy Durnin
drs.chiroweb.com