Question
QUESTION: Dr G! LBP initially manifesting itself as general muscular tightness associated with heavy (leg) weight training (and following PT for hip dysfunction/tightness + orthotics for functional leg-length discrepancy). Continued aggravating activity while seeking care as was manageable but steady escalation over 8mos until (rather quickly) crippling/disabling. 3mos discontinuation all activity, largely fetal position on side (escalating neck pain but very minor compared to LB and thought to be due to constantly bent downward down in fetal position, etc). Orthopedic surgeon. Neuro. Musculoskeletal. PT. Acupuncture. Massage therapy. Chiropractic (maninpulations/facet pops; left, returned, mainpulations + flexion/distraction; painful). Severe pain in extension; can't lie stomach or flat on back. Postural/alignment corrections (severe swayback largely corrected w/pelvic tilt, etc); suggests facet. Intraarticular (single-level) facet injection (local + steroid) ineffective (some alleviation under local w/exaggerated hyperextension but no improvement under normal range or sitting). Sitting worsened to point is impossible even momentarily (without pushing up off of seat w/legs or elbows); suggests discogenic component. Translaminal ESI - couldn't sit but felt better (~20%) in general for 48hrs. Transforaminal ESI (moving more anterior) - no benefit as of yet under local (but onset steroids may not have yet taken effect - 1.5 days). No dual-level MBB performed (my initial preference). No consecutive series of transforaminals (my next preference before translaminal) yet under presumption perhaps some do not experience benefit until duplication. SI not noted by any practitioner despite aforementioned hip dsyfunction & back pain in raising legs to knees with hip flexors. Neoarthrosis from articulation b/w transverse process & left sacroala (unilateral, left); but dismissed by pain management clinic as source of pain.
TOTALLY confused as to how to obtain a substantiated diagnosis - is very specific/centralized/localized pain yet cannot arrive at a substantiated diagnosis (posterior/anterior/both) despite various (perhaps not ideal?) injections, visitations, trials - so do not know how to direct course of action to regain life - and in any event no relief. Efforts to find comprehensive diagnostic clinic for out-of-town patients that can systematically perform all diagnostics/imaging/injections in-house or near-location that could move to for weeks/month until adequately diagnosed have been unsuccessful. Going somewhere (warm) for full rest (going horizontal w/knees up and walking but No sitting and No standing in place) and discontinuing any/all aggravating PT/chiro, discontinuing acupuncture/massage w/o material benefit, and injections for sustained period of time (months?) also being considered should such full/complete rest be indicated (am (very) fit, 15lbs (muscle) lost, do not believe core strength an issue, but undoubtedly some surrounding muscles contracted/guarding trying to prevent pain from movement (full range walking w/normal hip movement, extension, etc) while deeper muscles likely failed / turned off - but no perceived muscle spasms/pain, has become very centralized/sharp.
Minimum diffuse disc bulge (let's call L4/L5 - transitional anatomy), mild foraminal stenosis, slight retrolisthesis (L4/L5); no CT. Seated MRI being pursued (trying obtain rx). No medications (can't obtain rx). No
Any thoughts as to a prudent course of action would be much appreciated; if have any clarifying questions, please let me know. Many, many thanks.
Mike

ANSWER: Mike: This is mind-boggling!  You've surely had a long haul with this.  That's too bad, sorry.  My two thoughts are 1) have you done any Graston Technique deep into the lumbar region, and 2) do you have an unstable lumbar segment?   There is a program called FAKTR-PM (Functional and Kinetic Treatment and Rehab with Provocation and Motion).   This would involve you bringing your torso/back into pain-provocative positions while someone uses Graston Technique tools to work into various soft tissues.   The aim is to find the soft tissue bulls-eye that reduces the pain and promotes improved and pain-free function.   The other idea surrounds the possibility that you have loose or disrupted ligaments in your lumbar spine such that they are unable to hold the bones together.  This is called instability.  In such a scenario, you'd sit and your body weight would compress and force one vertebra off the other or cause the disc to bulge.   This phenomenon is well documented, thus the development of seated MRI for the lumbar spine.  When you lay supine in a scanner, your spine decompresses and instability will not be seen.  If you have instability, then you need to have a discussion with a spine surgeon.   I'd lean towards doing the seated MRI first, and if you re stable, try finding a Graston Technique provider and ask them to look into the FAKTR-PM courses being done around the country.

'Regards,and Good luck with this!

Dr. G

---------- FOLLOW-UP ----------

QUESTION: Thanks Dr G. Quick follow-up: I have done standing flexion/extension x-rays. A very 'mobile' spine but was noted as being generally 'stable' in this sense (different physicians had different interpretations but I'd summarize like that). I am unsure as to whether this is what you were referring to - degree of anterior/posterior stability OR vertical instability (i.e., vertical instability/compression when seated or bending backwards that would cause increased disc pain and subsequent localized but non-radicular pain?) I had not heard of / came across the latter. Next, would prolotherapy be good for this? Would chiropractice adjustment/manipulation and flexion/distraction (effectively Further stretching out the targeted LB ligaments vs tightening them) be BAD for this? Same chiropractor doing latter also is suggestive of former - so am confused. Thanks again.

Answer
Michael,

Funny you should mention prolotherapy.  After I sent my response to you, I thought, "Oh, and there's prolotherapy..."    Ways to determine if your spine is unstable, i.e. one bone sliding or squooshing over another one is to do lateral view standing flexion/extension x-rays, or, better, standing-loaded/weighted x-ray (with you wearing a weighted back-pack and also holding dumbbells across your chest) and hanging/suspension x-ray (with you holding a bar overhead and dangling.  The latter is a better way to show segmental slipping/deformity in either A-P or lateral directions.  Unfortunately, extremely few people have a set-up like this.  The better alternative is seated MRI since you can visualize disc anatomy.  Prolotherapy remains experimental and controversial, but clearly worth a try.  Sadly, depending on who's doing it, the cost is unreasonably high.   As for flexion/distraction: if it hasn't worked so far, then it's not likely to work.   If joint manipulation hasn't worked, odd are it's not likely to work.  The only exception is if the person doing the joint manipulation is doing something esoteric and calling it joint manipulation, or doing gentle mobilization and not conventional chiropractic high-velocity manipulation. There is a difference.     So, stick to the original game plan of seated MRI to rule out any form of disc or bone/segment instability.   If unstable, then try prolotherapy first.  If that doesn't work, then consult a spine surgeon.   If you have no instability whatsoever, then also consider trying prolotherapy as well as a Graston Technique provider that does FAKTR-PM.    

'Regards,

Dr. G