Question
QUESTION: Dear Sir,

My wife of 68,is suffering of back pain,usually on left-side,since last almost 10years.Jan.2003,Aug.2008,Aug.2011& now,July-2014.

Everytime,we referred to Orthopedic surgeon,who in turn ask for MRI of spine & observed some buldging/protusion between L4 & L5.He gave some pain killer & asked to carry out some excercise,demonstrated by Physiotherapist.
She recovered after about 15/20days.
This time she has pain at back on left-side,thigh & calf.Her weight is 36kgs.She has Varicose on the same leg,since almost last 30years.
We consulted Vascular surgeon,who in turn diagonised after dopler test that it is not causing such repetitive issue.He asked to consult Neurosurgeon.

After examining her MRI,he precribed following meds.
Shelcal-M(calcium with Vit D & minerals)Daily two tablets.
Cholecalciferol(Vitanova-D3)-once a week.
Calcitonin Nasal Spray-in alteranate nostril,once a day.
He asked to continue treatment for about 3months & also asked to carry out some excercise as he also observed same buldging/Protusion at L4/L5.
May I request you to review,whether these drugs as i understand are suppliments of Calcium can help!
I shall be obliged if you give your opinion,as this is reocuring issue.Would you also mind to suggest precaution to combat in future.
Do you think this is only Arthritis/degenerating bones,as she is regularly taking Rocaltrol since last 10years.
God bless you,for help.
Warm regards,
anil"

ANSWER: Anil ~
I apologize in advance for a lengthy answer to what seems to be a simple question but if you'll read through to the end I think you'll have a much better understanding of the situation you're in.

First, let me state for the record that I am totally against pain. But, I can't agree with the overuse, misuse, and inappropriate use of pain medications. It is important to understand that pain is not all bad for it serves a useful purpose like the smoke alarm in your home. It's actually a good idea to be alerted to the fact that a situation is brewing before the house burns to the ground although I will admit that the constant shrieking does become tiresome in a hurry. By all means turn off the alarm, but please don't neglect to fight the fire - the consequences can be devastating. Pain is no more and no less than the body's warning system that a physical or chemical stimuli has stressed your body beyond its ability to compensate.

It seems absurd to have to state the obvious which is that the appropriate treatment of pain is dependent upon identifying the cause of the pain, and yet most patients and many of their doctors seem to miss this vital point. As an example, let us suppose that a patient presents with severe leg pain made worse when walking as is the situation with your wife. Shall we prescribe pain medication and advise the patient not to do so much walking or should we perhaps try to determine the cause of the pain via examination and history, and only then determine an appropriate course of treatment?

There are many causes of leg pain. Let's say that the examination reveals a puncture wound on the bottom of the foot and the history indicates an incident whereby the patient stepped upon a rusty nail. This is starting to sound like tetanus - a bacterial infection. Maybe the examination reveals teeth marks and the patient reports having been bitten by a fox. This sounds like rabies - a viral infection. Does it make sense that the treatment for a bacterial infection and a viral infection would be different although the leg pain is the same? Is a painkiller or a calcium supplement really the answer?

Or, the examination reveals swelling and the patient reports falling from a tree. This sounds like a fracture. Maybe the examination reveals no injury at all, but the patient reports a history of back pain as is the case with your wife. This sounds like a pinched sciatic nerve. Does it make sense that the treatment for a fracture and a pinched nerve would be different although the leg pain is the same? Is a painkiller really the answer?

Bacterial infections and viral infections are chemical in nature and the appropriate treatment is chemical in nature, and this is delivered either by pill or by injection. I can't imagine how a physical treatment such as an ice pack or a foot massage could be considered appropriate treatment for tetanus or rabies whether these temporarily make the leg feel better or not. Alternately, fractures and pinched nerves are physical in nature and the appropriate treatment is physical in nature, and in this case I would suggest that a surgeon physically set the bone and a chiropractor physically manipulate the spine. I can't imagine how a chemical treatment such as a painkiller or a calcium supplement could be considered appropriate treatment for broken bones or pinched nerves whether the drug temporarily makes it feel better or not. Does it make sense that chemical problems require chemical solutions, and that physical problems require physical solutions?

Like smoke, pain is not the problem - it's a sign that you have a problem, and turning off the alarm is not the answer. Cover it up and learn to live with it at your own peril. However, if you put out the fire, you might discover that the smoke will soon go away by itself.

From your question it sounds as though you have tried physical therapy which is a type of physical intervention and it has not worked. My suggestion is to find a chiropractor well trained in the handling of chronic disc issues before the disc actually ruptures which will require the physical intervention known as surgery.

AUTHOR BIOGRAPHY

Dr. Michael L. Hall, D.C. practices at Triangle Disc Care in Raleigh, North Carolina specializing in Spinal Decompression for the treatment of acute and chronic neck pain and back pain due to herniated, degenerated discs. This is a conservative procedure for patients suffering with bulging or herniated discs, degenerative disc disease, posterior facet syndrome, sciatica, failed back surgery syndrome, and non-specified mechanical low back or neck pain.

For more information click on www.triangledisc.com or email [email protected] . Type "Free eBook - 101 Things I Need to Know about my Bad Back" into the subject line.


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

QUESTION: Dear Dr.Michael,

I am extremely grateful to spare time & reply in such elaborate way.Your explanation moved me & made to realize,before it is late.
I am short of words,as for the first time,I could see the way to combat agaist such recurrence.
If you kindly permit me,I am submitting hereunder the observation of radiologist of MRI & hope you may take your own time,to review & advise as I do appreciate that without seeing the films of MRI,it would be little difficult.But I feel,with grace of GOD,iam on right track to contact you.

Baroda Imaging Centre.
MRI Scan of Lumbar Spine. Rekha Desai-68.
MRI was performed using T1/T2Wsequences in multiple planes.
Mild scoliosis of dorso-lumbar spine is seen towards left side.Mild exaggerated lumbar lordosis is noted.Mild degenerative lumbar spondylotic changes are seeen in the form of marginal osteophytes & multilevel disc dessication.Patchy hyperintensity of spine is seen on T1W/T2W images.
Correlation with BMD is sggested to rule out Ostenpenia V/S osteoporosis.
Mild posterior disc bulge with small left foraminal disc protrusion is seen at L3-L4 level,partially effacting anterior subarachnoid space & indenting existing L3nerve root.Mild left neural foraminal narrowing is noted at L3-L4level.
Small postero-central disc protrusion is seen at L5-S1 level,effacting anterior epidural fat,indenting both traversing S1nerve roots.Bilateral mild neural foraminal narrowing & mild central spine canal narrowing(11.1mm)is noted at L5-S1 level.
Diffuse posterior annular disc bulge is seen at L4-L5 level.
Minimal posterior disc bulge is seen at L2-L3 level.
Mild facetal arthropathy is seen from L3-L4 to L5-S1levels.
Mild ligamentum flavum thickening is noted at L4-L5 & L5-S1 levels.
Thin fatty filum terminale is noted at L2-L3 level.
No central spinal canal stenosis is seen in this study.
Distal cord & conus appear normal.Both SI joints are normal.
No pre/paravertebral,epidural soft tissue or haematoma is seen.
Bilateral psoas & posterior paraspinous muscles are normal.
14.7.2014.

Sir,at the age of 76,I do suffer occasional pain on my left leg,but no knee issue.Would you advise some Calcium suppliment as Arthritis effect is diagonised & advised to keep walking & do some excercise.
I may be excused for requesting for advise,as I feel guilty to avail such services of your expertise at no cost.
Almighty may bless you,if you kindly reponse once again-though knowing it is too much to bother you.
Sir,I wish you would appreciate Anxiety level at this age,as both of us are Narrow-Angle Glaucoma patients.She underwent surgery 10 years ago & being monitored.While,I am fine after Laser surgery-5 years ago,with Latoprost in LE-IOP:14/15 & RE:12mmHg(No drops)
Thanking you,in anticipation & praying for every success in your walk of life.
With warm & sincere regards,
anil

ANSWER: Anil ~

So glad the information above was of some help. A calcium supplement may be of some benefit. Mild exercise such as walking will be a help as well.

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

QUESTION: Dear Dr.Michael,
Many many thanks for prompt response.
I am sorry but somehow you have not commented on MRI of my wife.

(I shall be highly obliged if you kindly comment with reference to the following specific lines:whether it is Alarming leading to likely degeneration at Spine?

Small postero-central disc protrusion is seen at L5-S1 level,effacting anterior epidural fat,indenting both traversing S1 nerve roots.Bilateral mild neural foraminal narrowing & mild central spine canal narrowing(11.1mm)is noted at L5-S1 level.Earlier MRI-Aug.2011, indicates spinal canal measurement at mild body level on T2sagital images as:L1:13mm,L2:13.6mm,L3:12.9mm,L4:15.3mm,L5:13.8mm.)

PLEASE IGNORE THIS IRREVALENT-QUERY & RESPOND ON MRI IN TOTALITY

Kindly also comment on treatment plan by Neuro-surgeon with due assurance that it will not be taken as second opinion.Please appreciate my Anxiety so as to derive positive results from treatment.

My wife is just 68,with only 36kg weight though she keeps high spirit,but unfortunately recuring issue is very painful.

This is my last request if you consider sympthatically.
GOD always bless you.

Warm regards,
anil.

Answer
If I understand correctly the neurologist recommended calcium supplements and 3 months of exercises. My comment is that it probably won't hurt but it probably won't help either.

You may have a common misunderstanding regarding spinal degeneration. This is not a yes/no or black/white condition. Spinal degeneration can best be thought of as much like a car tire going bald. Your wife already has spinal degeneration. It is either a little bald, medium bald, or a lot bald. Most of the descriptions used by the radiologist are small / mild which gives you an idea of which end of the scale you are. How alarming this is depends upon how much/how fast you intend to drive and for how long you intend to keep the car.