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Q: L4-L5 herniation L5-S1 DDD
asked by: mac43rn on February 12th, 2008
New User
I am in need of all the suggestions I can possibly get at this point. I will give you my history, current MRI reading, and treatments. I would appreciate and I am open to any suggestions.

34 year old male. with the above diagnosis on MRI performed in 1/2008

Four years ago I had my first real back injury and MRI showed "slight bulging" disc and the treatment that finally worked was an injection of L4-L5.

From time to time I would have trouble giving my children a bath, bending over of extended periods of time. I would describe the pain as tightness and would get some radiation into my right buttocks, but would eventually subside.

Then towards the end of December I slipped (one of those quick slips and then you catch yourself) and instantly had sharp shooting pain down my right leg. It actually brought me to my knees the pain was so bad. I was able to get back into my car get myself home and stated the rest, ice and ibuprofen treatment. I limped around over the Holidays and finally had enough as the pain was not subsiding. My FP doctor (knowing my history) ordered a MRI and it showed the above (title post) but I will read exactly what it states.

Findings:

L4-L5: Mild DD, central/right paracentral disc herniation with caudal extrusion on the right abutting with displacement of the adjacent right L5 ventral nerve root.

L5-S1: Mild DDD

Treatments as of 2/12/2006

Two epidural injections (corticosteroids, short acting numbing agent)

The first epidural was on Friday, January 18th. The day after I felt awful and really felt I a made a bad decision. However, when I awakened on Sunday I felt great. I still had intermittent pains shooting down my leg when I made certain moves, but overall I felt really well. Then on Monday it was back to same almost constant pain shooting down my right leg and then after awhile my lower back goes into spasms. I forgot to mention spasms are very predictable for me. After I have the shooting pain for an extensive period of time, the spasms always appear. I have tried several medications for the spasms and Valium 10mg and a TENS unit is about the only way to get the spasms to subside.

The second epidural was on February 1 and I had about the same result. However, this time I was pain free for two days vs. the one day I received from the first epidural. Needless to say, the epidurals are not working and the side effects I get from the steroids are not worth the trouble.

I am scheduled to see a neurosurgeon on Thursday at the Indiana Back Center in Carmel, IN. What can I expect? What would be my next step? I fell like I have taken all the conservative steps and I want to get my life back to normal.

Here is the problem. I finally had to go on short term due to the medications I am taking to make me "comfortable". Valium and Vicoden is what my doctor prescribed to me for the pain and the anesthesiologist said to continue on the meds after the epidural. However, my job requires driving and mixing the meds and driving is no different then drinking and driving. In addition, the position I sit while driving is by far the most uncomfortable position to be in. If I am stuck in this position for over 10-15 minutes it will instantly trigger a back spasm associated with the pain shooting down my leg.

I would appreciate any advice, suggestion that you could provide.

Best Regards,
mac
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algosdoc
replied on February 13th, 2008
Experienced User
The surgeon you are to see is not a neurosurgeon but an orthopedic surgeon. Most current orthopedic surgeons performing back surgery also have a fellowship in orthopedic spine surgery but this doctor probably graduated long before their existence, therefore the training may be limited. However sometimes experience makes up for lack of training.
As for your situation, sometimes discectomy is the best choice. If the disc herniation were larger, it would statistically resolve on its own, but given the description, it may be contained by the ligaments of the back and will not resolve soon. After two courses of epidural steroids without success, no more are indicated unless the physician does injections onto the nerve roots leading to the disc herniation...this would be done under fluoroscopy x-ray. If you had epidural injections without the use of fluoroscopy x-ray, there is a 40-60% chance the medication never made it to the correct location. Pain physicians, but not anesthesiologists, routinely use fluoroscopy x-ray for guidance of injections and appropriate administration would be with you lying down, not sitting.
Other options include inversion tables, chiropractic, use of "natural" drugs such as fish oil and methyl sulfonyl methane (MSM). The type of discectomies vary from open discectomy (usually performed by orthopedic surgeons involving an incision, removal of some of the bone of the back, then removal of the disc), microdiscectomy (same thing but through a portal using an operating microscope...usually not used by orthopedic surgeons), endoscopic discectomy (usually not used by orthopedic surgeons) in which no bone is removed, and disc decompression (through a needle or small portal removal of some of the center of the herniated disc to decompress it but leaving the herniation alone to gradually resorb).
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trumanpocket
replied on February 13th, 2008
New User
Mac,

I have the same thing you have. Two and a half years a go I ruptured my disc at the L4-L5 area. I could not even stand up without help. My FP sent me to a neurosurgeon and I had a discectomy. Got releif from the pain. A neurosurgeon is fine to see as oppose to a orthpedic surgon. Both can specilaize in back and if you are going to a back center, you will get a doctor who is well train in what you need.
I was good for a year after the surgery, but then started having trouble again. My neurosurgeon sent me to a Pain Management Doctor, which is an anesthesiologists trained in pain management. I get injections with a fluoroscopy x-ray and the work great for several months.
I would go to your neurosurgeon and see what they say. Usually they will try oral steroid meds, which also work great but don't last long, and physical therapy before any surgery.
I hope everything works out for you. I know how back the pain can be.

Linda
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mac43rn
replied on February 13th, 2008
New User
just some points I left out
I did try a small dose of a steroid dose pak my doctor prescribed to me in late december (i failed to mention that)

Also, both epidurals were performed while lying on a table (face down) and then they let the table portion below my waist down (so I am essentially I am lying on my stomach and they drop the bottom half of the table out from under me). I hope that makes sense.
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algosdoc
replied on February 13th, 2008
Experienced User
It appears your surgeon to see has been in practice 23 years. That is too long ago in residency for doing a orthopedic spine surgery fellowship. So, he has general orthopedic training unless he managed to do a spine fellowship somewhere along the way.

As for the epidural injections: if they used fluoroscopy with dye (radio-opaque contrast), then you probably had a good block. If it did not work under those circumstances, it will not work under any circumstances assuming the guy doing the block was aware of the need for the contrast dye to spread to the area of pathology. If no fluoro or no contrast, then consider repeating the epidural via a transforaminal route performed by a pain physician.
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mac43rn
replied on February 13th, 2008
New User
I have some more information for you
algosdoc wrote:
It appears your surgeon to see has been in practice 23 years. That is too long ago in residency for doing a orthopedic spine surgery fellowship. So, he has general orthopedic training unless he managed to do a spine fellowship somewhere along the way.

As for the epidural injections: if they used fluoroscopy with dye (radio-opaque contrast), then you probably had a good block. If it did not work under those circumstances, it will not work under any circumstances assuming the guy doing the block was aware of the need for the contrast dye to spread to the area of pathology. If no fluoro or no contrast, then consider repeating the epidural via a transforaminal route performed by a pain physician.


First of all thanks so much for your reply. This physician came highly recommended from others in the area and my FP. I am literally driving (I am not driving, my father is going to drive me) 3 1/2 hours from my house to see him. I have the epidural reports so I will give you some of the details.

Epidural number 1:

pt. was placed in prone position on chemo table. Under fluoroscopic guidance, L4-L5 was visualized. One-percent lidocaine infiltration. An 18-guage Husted was advanced until loss of resistance on first approach. No CSF or heme was seen. No paresthesia was elicited. After a negative aspiration, I injected Isovue 300 M 3 mL and obtained a lateral and AP epidurogram that showed excellent dispersion with enveloping the entire dural sac at at least 2 different levels. After a negative aspiration, we injected DepoMedrol 120mg and 3 mL of 0.5% Naropin. He tolerated this fine. We will plan on a second injection in two weeks.

Epidural number 2:

patient was placed in the prone position. His back was washed, and local anesthesia was injected in the skin. With fluoroscopy we identified the optimal spot for entrance into the caudal canal. An epidural needle was placed and with a good loss of resistance, we verified the optimal positioning with a fluoroscopy. A 120mg of methylprednisolone was injected together with 6 mL of 0.25% bupivacaine and saline up to a total volume of 16mL.


Anyhow there are the procedure notes from both epidurals just so you have all the details.

Do you think having a orthopedic surgeon work on my back is the best choice, or should I be looking for a neurosurgeon?

Also, what is causing the spasms. The pain (what would call a pretty much constant shock sensation) is there most of the time, and the spasms usually occur when the pain is at its peak. Is this just due to my back muscles compensating for whatever is going on???

And finally, I am feeling pressure from my employer to get back to work. Believe me, I NEED to get back to work, but I am not going to risk further injury, and more importantly driving while taking these meds.

Again, I appreciate everyone's help and advice
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antigone
replied on February 14th, 2008
Extremely eHealthy
I always feel a second opinion is valid. Go to a neurosurgeon. Many neurosurgeons specialize in back surgery. Chicago has many great options for neurosurgeons as does Northwest Indiana. If you are not having to trek too far to get to any of these locations I can name some very reputable docs. I am an RN and worked neuro ICU in these areas. Best of luck.
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algosdoc
replied on February 14th, 2008
Experienced User
I agree a second opinion from a NS may be in order. The epidural administration of drug probably did not work because it was not targeted to the disc level and the massive volume used during injection diluted out the steroid all up and down the spine so that only a small fraction was deposited on the affected nerve. A transforaminal small volume approach would have avoided this and placed the majority of the drug directly on the nerve. Also, the automatic planned repeat in 2 weeks of another epidural steroid injection has no basis in medicine or science. The depressive effects of the steroid on the adrenal glands from the first injection would not have worn off by 2 weeks, and repeated high dose steroid injection (120mg is fairly high) can lead to shock or severe systemic effects (short term for about a week) after the injection. Because of these two issues, I question whether your steroid injection was optimally performed, and therefore your poor results may be due to the choices made by the anesthesiologist. A pain physician would probably not have used this method. If your FP selected the anesthesiologist and now has selected your spine surgeon, it may be that the FP is not sophisticated enough to know the differences in practice, and referral patterns may be based on who one knows rather than what one knows. Consider a second opinion by a neurosurgeon OF YOUR CHOICE, not that of your FP.
Muscle spasms are not uncommon due to the irritation of the spinal nerve....the posterior part of the nerve courses to the muscles of the back and the anterior (front) part of the nerve goes to the leg.
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mac43rn
replied on February 28th, 2008
New User
algosdoc wrote:
I agree a second opinion from a NS may be in order. The epidural administration of drug probably did not work because it was not targeted to the disc level and the massive volume used during injection diluted out the steroid all up and down the spine so that only a small fraction was deposited on the affected nerve. A transforaminal small volume approach would have avoided this and placed the majority of the drug directly on the nerve. Also, the automatic planned repeat in 2 weeks of another epidural steroid injection has no basis in medicine or science. The depressive effects of the steroid on the adrenal glands from the first injection would not have worn off by 2 weeks, and repeated high dose steroid injection (120mg is fairly high) can lead to shock or severe systemic effects (short term for about a week) after the injection. Because of these two issues, I question whether your steroid injection was optimally performed, and therefore your poor results may be due to the choices made by the anesthesiologist. A pain physician would probably not have used this method. If your FP selected the anesthesiologist and now has selected your spine surgeon, it may be that the FP is not sophisticated enough to know the differences in practice, and referral patterns may be based on who one knows rather than what one knows. Consider a second opinion by a neurosurgeon OF YOUR CHOICE, not that of your FP.
Muscle spasms are not uncommon due to the irritation of the spinal nerve....the posterior part of the nerve courses to the muscles of the back and the anterior (front) part of the nerve goes to the leg.


It has been a week since my last epidural (under fluroscopy) this time with no steroids, only morphine. I felt great (other then the horrible itching) for about three days and then back to the same thing. I can say the pain does not shoot down to my big toe like it did before, the lower back pain (spasms) and pain in right buttocks is the same. It has become frustrating beyond belief, it is effecting my mental outlook (I wouldn't call it depression but almost a feeling of hopelessness). I return to my "new" doctor on Tuesday for a follow up and I am not sure what is left in their bag of tricks.

Here is a prime example, I sit down in a recliner to start typing this and I can already feel the spasms starting. Back to the bed I go the lay flat and stop the spasms.

Any suggestions would be greatly appreciated.
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rickso
replied on August 17th, 2008
New User
L4-5 herniation
I am 63, was in great health untill I was moving a 200 lb oxygen tanks, L4-5 heniations impringing on the L5 nerve, so I lnow what it feels like, no fun--
My Dr gave me a Epidural whiched helped for a short time-
Ok this is my suggestion for you, it has been six months for me and the nerve pain is awful at times, I take Tramadol to take the edge off, I had a driving job, sitting is a problem, if I was you I would just go to a Pt and let time heal it--YOU DO NOT WANT SURGERY of any type, I believe it will resolve in time , could be a very long time
I am doing this , you are much better off, I have never heard of any type of back surgery that was without complications of some type and long term effects-- your body will heal ,the back just takes longer--be patient, some dr's are looking for an excuse to do surgery, the goods one's aren't, they will tell you they believe in what they do, but if it will heal on it's own you are better off
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Wildturkey35
replied on May 31st, 2009
New User
I had a 3 level fusion in my lower back that enabled me to live without pain in my lower back for 4-5 years but now the pain is back. I have alot of structural problems in my mid and lower back... Sheuermanns disease and bad genes. I also have degenerating disks in my neck and midback which gives me pain every waking moment. With all that said I will not even consider another operation unless I lose use of my arms or legs. My doctor told me there are only 3 things he can do for my lower back since I already had a surgery. They are -- 1.injections 2. Meds 3. PT.

With that said I would try chiropractic or massage before going under the knife.
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Lliam
replied on May 31st, 2009
New User
Does your back feel better when you extend backwards, or bend forwards?
I bending forward makes it worse, and extending (leaning back) makes it feel better, then you may have a disc condition that is treatable without surgery.

I would use Goggle to search these terms:

Lumbar Extension Exercise
&
Thelumbardisc (one word)Sciatica Relief-Without Surgery
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kajl2006
replied on July 7th, 2009
New User
hi liam, what if te pain is worse coming back up, my husband cant even bend forward without pain but coming back up is even worse and he cannot bend his back any further then upright, even at upright hes in agonising pain.
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Lliam
replied on July 7th, 2009
New User
Kajl2006
He should see a doctor. But is sounds like a facet condition that may respond to manipulaiton or a facet injection.

Lliam
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kajl2006
replied on July 8th, 2009
New User
hi he has had an mri done and a sligt buldge is showing at l5 this disc is black and on the other side of it it is all black as well alsmost to the height of the next disc up. no one has explained any of this to us and we are being left in the dark. He is only 31 and this all only started after an 'axial loading injury' at work after going over a bump in the road in his tanker and the seat collapsed and his back took the impact instead. he as had an epidural and it did nothing for him. This has been going on sine 14th january and now his standard pain levels are a constant 8-9/10 compared to 5 two months ago. he has tried accupunture and hydrotherapy but neither of these things has helped, currently we are waiting on pain management specialist appointment and he has an orthapedic surgeons appt in september. Any insight into this would be great. Thanks
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Lliam
replied on July 8th, 2009
New User
If it is a facet syndrome, the pain clinic could inject steroids into the facet. A chiropractor could manipulate the facet as well.

Lliam
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HDT
replied on July 8th, 2009
New User
Im 20 years and had a kick in the back durin a rugby match two years ago, caused instant spasms but after 4 weeks felt fine. Year later had back pin again which started with spasms but left every 2 weeks or so but soon reappeard in the same fashion 4 times over the following 6 months. Now 2 years on after an MRI and Facit injections 3 times i still had a constant pain which started travelling down my left leg. My diagnosis was a perferated disk bulge pushing into the spine at L4 L5. I am very physically active and enjoy weight sessions but the most improvment ive shown is through chiropractic. Ive had manipulations and the flex distraction but have found results only come through solid work outside of the chiropractic office by strengthening your core muscles. The more stretches you do the more flexible and stronger you become and you will find you can achieve more tasks. I am still worried as i am not cured and want to play rugby again but believe there is a long road to recovery which will have to involve considerable hours strengthening and increasing the flexibility of my core. I dont mean to sound pesimistic but i cant see any miracle cures from surgery unless you dont want to lead a labour intensivelife. cheers
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