Question
The following is my MRI report...can you please suggest me possible treatment or solution...

Name: Latha Abraham
Age: 47 Y
Gender: Female

Clinical Notes: Acute PIVD with right sciatica
3.0 TESLA MRI LUMBO-SACRAL SPINE
(T1 and T2 sagittal and axial scans. STIR coronal of both SI joints. T2 sagittal of whole spine)
?Lumbar vertebrae shows normal signal intensity
?There is sacralisation of L5.
?Mild scoliosis to right side noted
?L4 vertebra shows mild posterior slippage over L5
?L4-L5 disc shows loss of signal on T2WI with central extrusion indenting thecal sac and narrowing nerve root canals, more on right side.
?Thecal sac diameter is as follows:-
Level      AP diameter (cm)
L1         1.70
L2         1.68
L3         1.61
L4         1.56
L5         1.36
?Facet joints are essentially normal.
?Conus is normal.
?SI joints are normal.
?Paraspinal soft tissues are normal.
?Screening study of cervico-thoracic spine shows normal signal intensity and alignment of vertebrae with no evident compression of thecal sac.

IMPRESSION
 Mild posterior slippage of L4 over L5.
 Sacralisation of L5.
 Degenerative change L4-L5 disc with central extrusion indenting thecal sac and narrowing nerve root canals more on right side.
 Essentially normal screening study of cervico-thoracic spine.

Answer
Dr. Abraham ~

So sorry for your troubles. When pain is the only thing you can think about life loses much of its joy.

There are 3 steps in the degenerative changes seen in a disc. First, the disc is drying out. On an MRI a healthy, hydrated disc will almost "glow" with whiteness whereas a dry disc will be rendered grey or black. The greyness is because the signal strength is different between hydrated and dry tissue and is what the radiologist means when she says "L4-L5 disc shows loss of signal". Second, as the dryness progresses the disc will physically begin to lose height causing the vertebra to be closer together. Space for the nerve is thereby compromised, this is referred to as spinal stenosis which is not indicated on your study. Third, the compounding stress on the bones of the joint results in calcium build-up which goes by various terms but is generically referred to as arthritis also not indicated on your study. This build-up is counter-intuitive because one might expect the bone to gradually wear away, but bone behaves much in the same way as skin - stress results in a build-up of skin referred to as a callous. The same happens with bone.

So, you have a disc at L4-L5 that has dried out to the extent that the outer fibers have weakened enough to allow the disc to bulge out. This extrusion is central and a little bit to the right and presses against (pinches) the spinal cord causing pain in the back at the site of the protrusion and along the impacted nerve which in your case runs down your right leg (sciatica) causing pain and a numbness-tingling sensation. You also have a slight curvature or scoliosis and an L5 vertebra that is not formed as perfectly as it might be - sacralization. This is not the cause of your difficulty and is seen often but simply results in added structural stress making it statistically more likely to have a disc problem at a younger age which is exactly what has happened.

Options:
1. Sometimes the extrusion will subside given time and gentle yoga type stretching exercises. Too much too soon will further tear the weakened fibers and it is difficult for anyone to know how much is too much and how soon is too soon. See a physical therapist who has seen many other similar patients. If it improves gradually do more to strengthen what is clearly a weak area. Continue the exercises at home forever to move the disc which acts to pump fluids through it and hopefully prevent a recurrence.

2. Try chiropractic. Start gently and as it improves be progressively more aggressive. This movement called an adjustment can move the joint further than your own muscles can move it with exercise - the anatomic range of motion as opposed to the physiologic range of motion, and can sometimes "suck" the extrusion back in. A chiropractor can also advise on exercises which you should continue at home forever to move the disc which acts to pump fluids through it and hopefully prevent a recurrence.

3. Get an epidural steroid shot. This acts to dry up the extrusion, but in my experience contributes to the fact that the disc is drying up. This can buy you some time. If you use that time to do gentle yoga type stretching exercises to strengthen the weak area and pump fluid through the disc you win. If it stops hurting and you fool yourself into thinking the disc is just fine now you lose and next time will be much worse.

4. Spinal Decompression Therapy is a non-invasive, non-surgical treatment performed on a special, computer controlled table similar in some ways to an ordinary traction table. A single disc level is isolated and by utilizing specific traction and relaxation cycles throughout the treatment, along with proper positioning, negative pressure can actually be created within the disc. It works by gently separating the offending disc 5 to 7 millimeters creating negative pressure (or a vacuum) inside the disc promoting the retraction of the bulging disc tissue. This negative pressure also pulls water, oxygen, and nutrients into the disc, thereby re-hydrating a degenerated disc and bringing in the nutrients needed to begin the healing process. See my website for further explanation www.triangledisc.com

5. Have surgery as a last resort; a good surgeon will tell you that too. In theory it works splendidly - simply cut away the extrusion, but especially with a central extrusion this also necessitates cutting away some bone and the muscles that attach to that bone. It doesn't address the fact that the remaining disc is still dry which is after all the problem so it tends to recur. It might seem as though fusing the vertebra together mechanically with screws and rods would do the trick but because each joint is designed to move a given distance this puts an additional work load on the adjacent joints which eventually fail in turn.

I hope this helps.