central disc protrusion in L4-L5 disc

Swaroop777,

It is a little odd that a spine surgeon would put a patient to strict bedrest and advise against any exercise at all now days. The usually practice in treating back pain for the past couple of decades has been to allow the patient a very short period of rest (less than 48 hours) and then get the patient moving. Bedrest has a whole host of problems associated with it.

Also, it has been shown that if a patient maintains good cardiovascular fitness, strong core musculature, and basic overall fitness, that the incidence of low back pain decreases dramatically. So, to tell a patient to do not exercise at all is not the usual recommendations.


Now, it is true that there is no specific exercise that will "cure" a bulging disc. That is a degenerative process and once it occurs, the clock cannot be turned back.

But, the patient's symptoms can be made better despite the structural problem.


Conventional training of spine surgeons used to teach that in cases of a discrete herniated disc, where the patient has a radiculopathy, that it did not matter how the patient was treated (nonoperatively or surgically), that at the two year mark, the patient would be at the same level.

But, currently, many patients do not want to put up with the symptoms, waiting for the body to resorb the herniated material, and the symptoms to subside. Since surgery has become much safer, they will opt for the surgery.


But, this is in cases of a discrete herniated disc. Your case is different in that you do not have an annular tear with a herniation of the nucleus pulposus. You have a broad bulge of the disc, which is causing the neural foramina to be narrowed. The foramina are the holes through which the nerve roots exit the spinal column. This narrowing is putting pressure on the nerve roots, which are innervating you region of your leg and foot. That is why you are having the symptoms in your foot.

The bulge will not be resorbed by the body, so in these cases, where there is correlation of the MRI study with the patient's examination, then about the only thing to relieve the pressure on the nerve is to surgically open up the area around the nerve root by surgical means.

This surgery is done for the leg pain, not necessarily the back pain. It is done to take the pressure off the nerve root.


But, by maintaining proper fitness, the back pain is usually addressed better. It may not take all of your pain away, but it will definitely keep it from getting worse as you age.

Patients who are in poor physical condition have a much higher rate of mechanical back pain.


So, we usually advise patients to do any activity that does not cause them significant discomfort. Low impact aerobics or water exercises are especially good. Yoga, tai chi, stretching are also recommended to maintain flexibility. Light strengthening exercises to keep the abdominal, oblique, and back muscles strong are also very important.

Proper biomechanics are absolutely mandatory when lifting objects during the activities of daily living. Proper standing postures when standing for long periods of time are needed. And the proper posture is not necessarily what your mother told you to do (ie stand up straight). Standing with the weight on both feet equally will actually cause the low back to hurt. So, when standing, such as at the ironing board or washing dished, it is recommended to stand on one foot, shifting your weight to that side. Also, by placing a small box (3 to 5 inches high) for the relaxed foot to rest on is even better. This is why there is a rail around the bottom of standing bars in saloons. Not that they knew the best biomechanics, but they did know that patrons would stand there longer if they were comfortable. The shift your weight of the other foot every so often. By doing this you can stand for extended periods without your back causing you discomfort.


There are a bunch of other tips that can be found concerning the back. But, in general, keeping fit is the way to go for the back pain. However, if the leg/foot pain is really bothering you, then you may have to have surgery to help that. The newer, less invasive procedures have shown very promising results in the proper patient. If the indications are correct, these procedures can give the patient quite a bit of relief.


Speak with your surgeon and discuss all of your options, and the risks and benefits associated with each. Good luck.

Hi,

I Have severe back pain and this is what I can see it in the CT-Scan. My Doctor asks me to get MRI and am not sure what to do here, please suggest. Information in the Report:
1. L2/L3 Unremarkable
2. L3/L4 Small Central disc protrusion, but no compromise on existing nerve roots or central canal. Mild Facet Degenerative disease.
3. L4/L5 Small Central disc protrusion, but no compromise on existing nerve roots or central canal. Minimal Facet Degenerative disease.
4.L5/S1 No significant disc protrusion. The existing nerve roots and central canal are not compromise. Mild Facet degenerative disease only.

chaitu66,

It used to be that MRI was much better to look at the soft tissues than the CT scan. However, now the CT scan has improved significantly. However, the MRI is still better for looking at the disc complex, which the CT scan you posted did not mention.

I can help you with the terminology of the CT scan.


"1. L2/L3 Unremarkable"
>> This is self explanatory


"2. L3/L4 Small Central disc protrusion, but no compromise on existing nerve roots or central canal. Mild Facet Degenerative disease."
>> Here you have a small disc bulge, which is limited to the posterior aspect, centrally located in relation to the spinal canal. It does not cause any compression on the nerve roots within the lateral recesses or in the spinal canal. The facet joints in the posterior elements of the vertebra have mild DJD (degenerative joint disease).


"3. L4/L5 Small Central disc protrusion, but no compromise on existing nerve roots or central canal. Minimal Facet Degenerative disease."
>> This is essentially the same of the disc above


"4.L5/S1 No significant disc protrusion. The existing nerve roots and central canal are not compromise. Mild Facet degenerative disease only"
>> This disc space only has the mild facet joint DJD.



As to the significance of these findings, that is something you really need to discuss with your surgeon. All findings on any study have to be correlated with a patient's history, symptoms, and physical exam.

But, usually from these findings a patient would not be expected to have very many symptoms. The findings are very mild or minimal.

So, if you are having more symptoms than what would be expected, you might want to get the MRI. Again, the MRI can evaluate the status of the disc complexes, to see if there is any DDD (degenerative disc disease).

Hope that helps. Good luck.

Hello i just got news of my MRI. I am 29 yr old male and I am in need of help to better understand what is being said. Are all the "stenosis" terms used here the same thing as "Lumbar spinal stenosis"? How bad is this? What may have caused it? I am in unbearable pain and my tolerance is running low. Any information you could help me with would be greatly appreciated. thank you.

FINDINGS:
Normal alignment of the lumbar spine. No fracture or listesis. Vertebral body heights are preserved. Mild Disk desiccatation and height loss at L3-4 and L4-5. Visualizd spinal cord signal normal on all sequences. Normal bone marrow signal. No inflammatory change identifed.

AXIAL IMAGES:

T12-L1 through L2-3: Small anterior protrusions versus thickening of the anterior longitudinal ligament. No central canal or foraminal stenosis. Mild bilateral facet arthropathy perdominantly at L1-2.

L3-4: Diffuse disk bulge with mild to moderate bilateral facet arthropathy and ligamentum flavum hypertrophy resulting in mild central canal stenosis. Mild bilateral forminal stenosis left greater then right.

L4-5: Central posterior disk protrusion measuring 13mm wide and extending 6mm inferiorly along the posterior margin of L5. The disk protrusion causes moderate to severe lateral recess narrowing bilaterally left greater then right and severe focal central canal stenosis. Mild bilateral facet arthropathy right greater then left. Mild right forminal stenosis.

L5-S1: Normal disk configuration. No central or foraminal stnosis. Partial sacralization of L5.

IMPRESSION:
1. Central posterior disk protrusion at L4-5 causing severe central canal stenosis and lateral recess stenosis
2. Diffuse disk bulge at L3-4 causing mild central canal stenosis.

bentouttashape,

I can help you with the terminology:

FINDINGS:
>> This is the overall general impression of how the spine looks.


“Normal alignment of the lumbar spine.”
>> The lower part of the spine, in the low back (there are five lumbar vertebrae), are all lined up normally. In the lower back there is a normal lordotic curve to the spine. The whole spine together (when looked at from the side) has several curves, again, these are normal. If they were not there, it would be abnormal.

“No fracture or listesis.”
>> There are no acute fractures noted within the spine. There is no spondylolisthesis. A ‘listhesis is the movement of one vertebra over (off of) another. This can occur if there is a defect in the posterior ring of the vertebra, which allows the vertebral body to slide forward, off of the one below it.

“Vertebral body heights are preserved.”
>> There are no pathological compressions of the vertebral bodies. These can often be seen in elderly patients who have osteoporosis.

“Mild Disk desiccatation and height loss at L3-4 and L4-5.”
>> There is MILD loss of water in the discs at the levels L3-4 and L4-5. This is one of the very early signs of DDD (degenerative disc disease). When the discs start to lose some of their water content, they do not stand up to the stress of compression as well as before. This will be manifested by loss of height of the disc.

“Visualizd spinal cord signal normal on all sequences.”
>> The spine cord is normal. The different types of MRI images which can be produced are called “sequences”. So, on all of the images, the cord appears to be normal.

“Normal bone marrow signal.”
>> The bone marrow, which is contained within the vertebral bodies, is normal.

“No inflammatory change identifed.”
>> There is no inflammation noted around the spine, or in the paravertebral soft tissues (tissues around the spine, such as the muscles).



AXIAL IMAGES:
>> These are images looking at the spine from the side.


T12-L1 through L2-3: Small anterior protrusions versus thickening of the anterior longitudinal ligament. No central canal or foraminal stenosis. Mild bilateral facet arthropathy perdominantly at L1-2.
>> The radiologist has noted that the soft tissue in the front of the vertebral bodies is somewhat thicker than it should be. He/she cannot tell if this is due to some SMALL protrusion of the disc in the front of the vertebral bodies (when discs compress down due to loss of water content, they can expand outward a little, sort of like an underinflated tire) or if it is due to some thickening of the stout ligament that runs up and down the front of the vertebral bodies (the anterior longitudinal ligament).
>> At these levels there is no narrowing (stenosis just means “narrowing of”) of the spinal canal, where the cord is located. There is also no narrowing of the neural foramen. The word foramen just means “hole”. The neural foramen of the holes through which the nerve roots exit the spinal canal.
>> You have some MILD degenerative changes in the facet joints. The facet joints are located in the posterior elements of the vertebrae (the back). These are obliquely oriented joints, which allow the vertebrae to move against each other (as when flexing and extending the back). These joints are synovial joints, which means that the joint surfaces are covered with articular cartilage and the joint is surrounded by a joint capsule (holding in the joint fluid). So, these joints are susceptible to degenerative joint disease (DJD, also called OA osteoarthritis), just like the knee, hip, elbow, etc.


“L3-4: Diffuse disk bulge with mild to moderate bilateral facet arthropathy and ligamentum flavum hypertrophy resulting in mild central canal stenosis. Mild bilateral forminal stenosis left greater then right.”
>> At this level, the disc bulges out a MILD to MODERATE amount is a diffuse way (as opposed to having one spot ballooning out a lot).
>> The ligamentum flavum is a bunch of ligaments which connect the inside of the vertebral rings together. There is a little bit of enlargement of these ligaments (especially at this level). As a result, there is a small decrease in the amount of space on the inside of the vertebrae (the spinal canal).
>> The facet joints here have a little bit more degeneration.
>> The neural foramen are MILDLY narrowed, with the left side being a little more narrowed than the right. But, there is no mention of the nerve roots being affected in any way.
>> Of note, even if there is a small amount of spinal stenosis here, there is no solid spinal cord to be affected at this level. The solid cord ends up around the level of T12-L1. Below that level, it is the cauda equine (tail of the horse), or the terminal nerve roots contained within the thecal sac, floating in the CSF (cerebrospinal fluid).


“L4-5: Central posterior disk protrusion measuring 13mm wide and extending 6mm inferiorly along the posterior margin of L5. The disk protrusion causes moderate to severe lateral recess narrowing bilaterally left greater then right and severe focal central canal stenosis. Mild bilateral facet arthropathy right greater then left. Mild right forminal stenosis.”
>> Here, it sounds like there is a herniation of the nucleus pulposus (the jelly like center of the disc complex), which has migrated backwards and down, along the back of the vertebral body.
>> This disc material narrows the lateral recess significantly, of the left more than the right. The lateral recess is a groove which leads up to the neural foramen, which the nerve root runs in. However, the foramen is only mildly narrowed.
>> It is at this level, that the central spinal canal is significantly narrowed.
>> Again, there is some mild degeneration of the facet joints.



“L5-S1: Normal disk configuration. No central or foraminal stnosis. Partial sacralization of L5.”
>> At this level, the disc complex appears normal, without evidence of any narrowing of the central canal or neural foramen.
>> The L5 lumbar vertebra has not completely separated from the sacrum. This is just the way you “were made” in utero. This is actually a common finding.



“IMPRESSION:
1. Central posterior disk protrusion at L4-5 causing severe central canal stenosis and lateral recess stenosis
2. Diffuse disk bulge at L3-4 causing mild central canal stenosis.”

This is just a recap of the already mentioned findings.



So, you have one disc level which has a herniation which is significantly narrowing the central canal and the lateral recess.

As to the significance of these findings, that is something that you will have to discuss with your surgeon. All “findings” on any study have to be correlated with the patient’s history, symptoms, and physical examination.

Not all patients with the same findings will have the same set of symptoms. Which is why you need to discuss the study with your surgeon.


Good luck.

Gaelic,
Thank you for replying so soon. If i may ask, is there any think that you think that may have caused this to happen. I am also curious about the degenerative disk disease will it still develop over time along with age? Is there a way to prevent it from getting worse or a cure maybe? Is what i have a combination of a disk herniation, spinal stenosis, arthritis, and early stages of degenerative disk disease?

bentouttoshape,

Until the advent of the MRI, DDD (degenerative disc disease) was thought to be only an "older patient's" problem. Since there was no way to actually image the soft tissues (x-rays and CT scans look at bone), the only way to know if the discs were degenerating was an indirect method. When looking at x-rays, the "space" between the vertebral bodies (where the disc is located), would be narrower, indicating that the disc was losing height, thus it was inferred that the disc had degeneration. This was usually only seen in the elderly.

Once the MRI came into being, we started to see "finding" that were not really known about until then, such as the early stages of DDD and disc "bulges". As to what the significance of any finding actually is, really has to be taken in light of what the patient's history is, what symptoms he/she is having, and what the surgeon finds on physical examination.

We do not really know exactly when or why the discs begin to degenerate, AND why some patients seem to have a lot of pain with certain findings while other patients with the exact same findings do not have the same level of discomfort.


The herniation of the nucleus pulposus at L4-5 is probably of more concern to your condition than your MILD DDD.

This herniated naterial (often called a "slipped disc" by lay people), is narrowing the lateral recess significantly. Though the radiologist does not state that the nerve root is being affected, usually when the lateral recess and/or neural foramen are narrowed, that can put pressure on the nerve root. If the nerve root is being compressed, it will usually cause symptoms in that root's distribution. Such as when the L5 nerve root is compressed, the patient will have pain, numbness, tingling in the foot and outer leg.


You also have a one level central stenosis. Again, this used to be mostly seen in patients over the age of 50. Usually, when patients have lumbar stenosis, they manifest the problem with neurogenic claudication. This is pain in the legs after walking a specific distance. The patient has to stop and sit down (or bend over at the waist) to make the pain go away. This has to be differientiated from vascular claudication, which also causes pain in the legs, but this is due to poor circulation. These patients can just stop walking for a few moments (do not have to sit or bend over) to make the pain go away.


Pain in the lower back is always a difficult problem to figure out where it is coming from. Spine surgeons know that they can do certain procedures (such as a laminectomy, disectomy, etc) to get rid of leg symptoms, but doing surgery to get rid of back pain is not as reliable. If a patient has severe DDD, fusion so that the vertebral bodies are no longer moving over each other, often reduces the discomfort (will not eliminate it completely). But, again, this is usually only done for patients with severe DDD.


Unfortunately, with our current sedentary population, musculoskeletal back problems are rampant. Sometimes, spine surgeons can do something. But, there is still so much about the pain generators about the spine that is not known about.


So, again, it is very important for you to sit down and discuss your findings with your surgeon. The findings on the study have to be correlated with your history, symptoms, and exam. Sometimes, the patient's symptoms can be explained by the findings on the study, but then sometimes, they cannot. That is when the problem becomes really difficult.


Hope you find some treatment for your back problems. Good luck.