Question
QUESTION: Hi,

Can u please explain to me in laymans terms what this mri report means .

Im 29 years old software enginner. i have back pain for last 6 months, earlier i ignored it, i can sit for more than 2 hours, the pain is radiating in the leg too (both)... and i feel a tingling in my private parts.
I have been given some excerise and no medicine.

Here is my report.

Lumbosacral spine was stuides with 4mm slices.

There is seen straightening of lumbar spine. the lumbar vertebrae reveal normal marrow signal intensity. the l4-5 disc is of lower signal on T2 images signifying denegeration. The other lumar diusc are of normal signal. There is evidence of posterior central and left paracentral protusion of l5-s1 disc casuing thecal sac indentation. Diffuse disc bulge of l4.5 dis is identifies with an annular tear in its posterior central componenet causing thecal sac indentation and mild bilateral foraminal compromise. No other disc bulge is noted.

Impression:-1)Starightening of lumbar.
2)posterior central and left paracentral protusion of l5-s1 disc casuing thecal sac indentation.
3)Diffuse disc bulge of l4.5 dis is identifies with an annular tear in its posterior central componenet causing thecal sac indentation and mild bilateral foraminal compromise.


What does thia mean. ??? Am i suppposed to have cauda symdrome ???  Will this cost me my job ???

ANSWER: Hi Veena,

You have the last disc in your lower back dried up and herniated with a sight tear in the casing. This doesn't usually require surgery since flexion/distraction performed by a D.C. can decompress this disc in 95% of the cases.

I'm going to be honest though, the annular tear is extremely difficult to treat. It will heal over with time, about a year. You can take glucosamine sulfate 3x in the A.M. and 3X in the P.M. 6/day at 500mg with 30% pulsed ultrasound overlaid with interferential therapy and ice. This will cut the healing time to 5-8 weeks. Only a D.C. can do this, call around for ones that do spinal decompression or F/D. Make sure they also have therapeutic modalities such as ultrasound and E-stim.
Stay away from exercise and epidural injections since this will only prolong your condition.

Here is some additional information on annular tears,

A previous article in this column1 presented the classification of lumbar herniated disc pathoanatomy and symptomatology, drawing on the Recommendations of the Combined Task Force of the North American Spine Society, he American Society of Spine adiology, and the American Society of Neuroradiology.2 This article continues the discussion with 2 additional related pathologies - annular tear and internal disc disruption.

Interestingly, the term annular fissure has been suggested as preferable to annular tear since the former does not imply a traumatic etiology, as the latter seems to do. Since the term annular tear is used widely, however, the Combined Task Force decided to accept it. Thus, the terms fissure and tear are used synonymously, with neither conveying any knowledge of etiology, symptomatology, or need for treatment.

In vitro studies have shown that the posterior annular fibers are among the first tissues of the intervertebral disc to fail.3,4 This particularly occurs with overload (usually repetitive microtrauma) in a combination of flexion, rotation, and compressive loading. This failure first occurs circumferentially in the outer layers of the posterior annular wall (Fig. 2) and is called a concentric tear. A small tear of this type is essentially invisible to current imaging studies, but is suggested as among the most common causes of acute low-back pain.5,6 With repeated injury, this tear can enlarge and become inflamed. At that point, the inflammatory response may be visible as an area of increased signal intensity-a high-intensity zone (HIZ)-seen on 12-weighted magnetic resonance

Further injury can cause failure that permeates deeper through the annular layers on a radial path toward the nucleus.This is a radial tear, shown in Fig. 3, and may also be visible as an HIZ. Both concentric and radial tears are potential pain generators, with symptoms being mediated by nociceptors in the posterior annulus.

It is important to note that a radial tear can also originate from the deepest layer of the annulus and extend outward toward the periphery, either in a transverse or cranial-caudal plane. This essentially creates a channel through which a degenerating nucleus may distort, and is the basis for internal disc disruption (IDD).

Defined as disorganization of the structures within the disc space, IDD is not visible on x-ray, MRI, or CT scans; that is, no decreased disc height, distortion of the posterior annular margin, osteophytes, or desiccation is present. If any of these findings did exist, the pathology would properly be called degenerative disc disease. Instead, IDD is visible only on discography, the procedure where contrast material is injected into the nucleus under fluoroscopic imaging.

Fig. 4 depicts IDD that is enclosed by an intact outer annulus-consequently, it is further described as contained. In this case, if posterior annular nociceptors were stimulated, symptoms would be present. The outermost layers of the annulus can also be torn, however, as shown in Fig. 5. This essentially allows communication between the nucleus and the epidural space and is classified as uncontained, or colloquially, a "leaking disc." Such uncontained pathology can lead to chemical radiculopathy through inflammatory and/or immunologie processes.7

Like annular tears, IDD may or may not be associated with symptoms. When symptoms are present, the term IDD syndrome or painful IDD is used, or sometimes simply painful disc, which, being less specific, could include annular tears, as well. Such discogenic pain does not involve nerve root damage (except for the leaking disc, which may cause chemical radiculopathy) but can result in referred lower-extremity pain. This has been shown in numerous studies involving noxious stimuli of the discs through injections.8-11 Such provoked discogenic pain often extends below the knee to the leg.8-11

Diagnosing discogenic pain, however, is controversial. This is primarily because the gold standard for such diagnosis, provocation discography, is controversial in itself. Provocation discography involves the injection of a contrast material into the nucleus under a given pressure and the assessment of the patient's pain response. In theory, pressurizing the nucleus puts a stimulus on the annular nociceptors, somewhat analogous to palpating the annulus. In a normal disc, this is said to be painless; in a painful disc, it would reproduce the patient's exact pain. Carragee, et al., however, have demonstrated that the false positive rate for pain provocation discography can be as high as 25% in asymptomatic individuals, 40% in those with chronic pain, and 70% in patients with abnormal psychometric profiles.12,13 Nevertheless, others suggest that discography can be more specific if used in cases when discogenic pain is considered highly likely, based on history, physical examination, and imaging.14,15

This 2-part article on the pathoanatomy of lumbar intervertebral disc disease emphasized terminology and classification, rather than management, which is beyond the scope of this article. In closing, however, it is worthwhile to note 2 points. First, some evidence suggests that doctors of chiropractic frequently treat these types of disc lesions.16 In fact, it would be expected that DCs would regularly encounter such conditions, perhaps without even being aware of them, given the ubiquity of the problem and the difficulties posed by diagnosis. Second, a recent systematic review evaluated the evidence supporting high-velocity, low-amplitude manipulation as a treatment for symptomatic lumbar disc pathology.17 The authors found that some positive outcomes have been demonstrated; the overall evidence, however, is limited in quality and quantity. Therefore, no strong conclusions can be made at this time. More work is needed to understand the role that HVLA manipulation and other chiropractic adjustive procedures can play in the management of lumbar intervertebral disc pathology.


Why do you ask about cuada equina syndrome? This is extremely rare and means you have lost bowel and bladder control.

Here are some other options,

http://www.chirogeek.com/003_IDD-Tutorial.htm

I can't answer if it will cost you your job, that depends on your employer, if you do, take it up legally under the FLMA (Family leave medical Act).

Hope this helps,
Dr. Timothy Durnin
drs.chiroweb.com

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

QUESTION: First of all thanks for your time.

I said it abt my job cos.... since my job is sitting and im having dificulty sitting, can i still continue with my job with the pain.... wont it cause me more harm ???
what r the chances of paralysis ??

One last thing, today i heard abt "Ozone cure for slipped disc" cani have this done.. will it gv me my normal life. ??

THanks...
Well to be sincere im scared of uada equina syndrome, hence asked whether ill get this....
i didnt loose bowel and bladder control.
ANSWER: Yes Veena,

Sitting is the worst thing you can do with a back problem next to lifting, avoid it if at all possible.

The chances of paralysis are 0, never happen.

Never ever volunteer for a new procedure when micro-discectomy is much more effective and proven to work. Your biggest problem isn't the herniations, they can be decompressed without surgery, it's the annular tear, I already told you how to treat that. It's slow but your options are limited, there is no quick fix when you have a multitude of problems. Try the F/D and see if you can tolerate it while getting therapy on the tear. If not, concentrate on the tear first. Hope you feel better soon,

Dr. Timothy Durnin
drs.chiroweb.com

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

QUESTION: No Sitting???
Thats what i was scared of . Then how do i work ?? How long shd i take off from work ?? My work is my passion and its has been my life .

Talking to u has cleared a lot of doubts, my doctor here scared me about this.
He said since  im getting leg pain and tingling thing in my private parts , its very serious... and people get paralysed and all... Hence im damn scared...

People sometimes get paralyased due to slip disc right?? When does this happen ??


I will definately go to a doctor for the anular tear and update u about my progress.

Currently the only thing im doing is a excerise with some muscle relaxant.  

Answer
Hi Veena,

Chances of getting paralyzed are 0, you can sit but not for more than 10-15 minutes. Move around as much as possible.

Discontinue any exercises, do only stretches, the former will only worsen your condition. Get started on F/D as soon as possible and take 3 grams of glucosamine sulfate with MSM/say. See your D.C. for physiotherapy and you should still be able to work, it just may take a bit longer to improve.

Dr. Timothy Durnin