MRI and physio says steroid injection....

[crazycrow]

Wrote on here a while ago about back pain at l3/4 level, with numb toe and got some good advice to go for MRI and physio, had MRI which says; widespread degenreative disc disease in 3 lower lumbar discs with reasonable preservation of the disc signal elsewhere in spine. Focal and plate degenreative changes in lower 3, small braod based degenerative disc bulges that no not encroach on the spinal canal. No evidence of focal nerve root impingement & moderate facet joint degeneration noted.
So...had physio with exercises to strengthen core, but hasnt made a scrap of difference to the pain and my big toe is numb, yet MRI says no nerve impingement.
So..I want to avoid a steroid injection at all costs and wondered if anyone had a good suggestion??....

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[gcoe]

Diagnosis
Numbness of the big toe is suggestive of injury to the spinal nerve of the 5th lumbar nerve. that nerve runs out between the fourth and fifth vertebrae. Even though there is no report on the MRI of nerve impingement, clinically the presentation contradicts the MRI. a normal MRI is not very accurate at picking up nerve impingement although it is good at picking up lots of other spinal disorders. MRI Myelography may be better - a more specialised MRI but I don't know how accurate it is.

Of course there could be other sources of impingement of the nerve but given you have accompanying back pain nerve root impingement would be the most likely site.

Treatment options

Did your physio try manipulative techniques? I would think going to a good manipulative physiotherapist may be worth a try. Such techniques as rotation mobilisations, intermittent traction might be selected by the therapist, based on the findings from the examination. sometimes a system of exercises based on the Mckenzie method can help. There are also other exercise programmes other than core stability exs that can be helpful

Do these techniques work? Unfortunately evidence for such techniques is limited. There is strong evidence that traction doesn't help sciatica. Other manipulative techniques have varying results. Exercise therapy has been shown to be beneficial in the long run over no exercise.

One good thing about a manual therapy approach is if it is going to help you get results quickly. So if it isn't going to work you should know after a few sessions.

With steroid injections - many people prefer to avoid this. Why are you not keen on this option? I am asking as you may have had a bad experience or no someone who has. In terms of the evidence there are a number of good studies but no conclusive results - some studies support the use of injections and some do not.

[physiobob]

One should condsider that the lower limb nerves run through the thing, left and foot. I would get your physio to look for possible sites of entrapment in those areas. Perhaps some neural testing and posturing will highlight where the tract is getting blocked. Releasing this (joint, fascial tension etc) might well resolve the big toe issue.

In summary don't just blame the back itself as we all (well most of us) exhibit those changes you mention on your MRI. One might say in fact that they are pretty darn normal.

[gcoe]

Physiobob is making a good point there. so there are a few things to consider.

A clinical examination with and experienced therapist that includes not just a full examination of the lower back but also consideration of the nerve that supplies the big toe (from the back, all the way along the leg to the toe) at this stage maybe the best way forward.

[crazycrow]

thanks for the advice - but other than go to my GP, get referred to a physio I dont see where else I could go to get a clinical examination with an experienced therapist - I thought that was what I was getting? I'm not blaming my back at all its just what the physio told me, in fact the pain is well right of my spine anyway. I have now been sent with a letter to go for an injection (but dont want it) - so what sort of therapist should I look for?

[gcoe]

get referred to a physio I dont see where else I could go to get a clinical examination with an experienced therapist - I thought that was what I was getting?

The physio has offered you one method of treatment which hasn't achieved anything. I don't know if your physio had other ideas in mind or not. I also don't know what your physio did or did not do in their assessment.

So the first thing is have you got the right diagnosis and which might indicate the right treatment? Given the treatment didn't work the first thing to know is if the diagnosis was right.

The second thing is different treatment options. if one thing doesn't work, another approach might. Why don't you discuss this with your physio? See what else they can come up with. If you are not happy with the response and/or want another opinion you could see a second physio. I would suggest you see a musculoskeletal physio with a qualification in manipulative physiotherapy.