Disc Bulge - Sciatica pain for 4 months

[jannie]

Hello All,

I am a 50 year old female, fit/healthy although haven’t done any regular exercise for 15 years or so. I have no history of any back related problems. 2 years ago I had a couple of brief episodes of mild pain in the back of my right buttock when turning over in bed which may or may not be related. Up until the start of my problems I did spend considerable amount of time sat in front of the PC and had a desk job for 20+ years.

Four months ago pain started in my right calf with pain starting in my right buttock a month or so later together with pins and needles, tingling in right calf and foot. Now I have a deep “sore” type pain in the side of my buttock and a continual deep cramp like pain in my calf causing a limp. At worst I also get pain in the front right hand side towards the groin area, in my lower back on the right hand side and my right foot. The tingling, pins and needles have gone, although when I sneeze a sharp pain does still shoot down my leg to my foot.

The pain is worse when lying down, either on my back or my good side and driving also aggravates it as it is the “accelerator” leg. Sitting is also painful.

Went to GP in April who ordered pelvic, spine lumbar x-rays. Results were:
- Slightly relative left hip joint space narrowing
- SI joints normal
- Grade 1 anterior listhesis on L5 on S1 with suggestion of bilateral pars interarticularis defects
- Slight disc space narrowing a the L5-S1 level

Pending referral to a spine consultant I self-funded a lumbar spine MRI in June. Results were:
-Hyperlordosis but no scoliosis
-Grade 1 lytic spondylolisthesis at L5/S1 with signs of degenerate disc but no signs of any acute instability. However disc is bulging significantly into the right outlet foramen likely to cause severe right L5 nerve root impingement
-Atrophy of the paraspinal muscle bulk

I attempted to get clarification from the radiologist whether the MRI evidenced actual nerve root compression but he replied “ you have a disc bulge which is likely to cause nerve compression but these scans are never conclusive… such disc bulges can go back on their own although it can take up to a year. However, in the presence of the spondylolisthesis the disc deformity is likely to be permanent.”

Treatment – The pain, certainly not excruciating, is manageable with regular ibuprofen. I do use ice, when needed, and I do extension exercise, but not regularly as sometimes this can aggravate things. Before having the MRI I did have 3 sessions with a sports therapist (massage, pelvic alignment) which did help at the time but in view of the MRI results we agreed to stop treatment pending me seeing a specialist.

My symptoms would suggest a compressed L5 nerve root but with all the other stuff going on I wonder if there’s another or contributory explanation? I am hoping it looks worse than it actually is! I am seeing a spine consultant on 10th August but in the meantime it would be really helpful to have any opinions. Also any advice on self-treatment exercises, stretching, etc. I am making a conscious effort with my posture: standing/sitting correctly, not bending forward from the waist and generally trying to keep as upright as possible. Thank you.

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[gcoe]

Yes what you describe sounds a very typical sciatica. While only your clinicians can diagnose this, All of what you described fits the sciatica picture.

The right disc bulge visible on the MRI could well explain the incursion of the nerve root while the spondylolysthesis is probably unlikely to be the culprit - the shift sounds too minor. However all this has to be taken in perspective - the diagnostic accuracy based on an MRI is not that great and lots of people have sciatica without demonstrable signs on and MRI. Likewise you can have huge disc bulges and no symptoms.

The fact that you have "atrophy of the paraspinal muscle bulk" may indicate that you have back muscle weakness and/or those local muscles that control and stabilise those spinal segments may be disrupted. In the former case strengthening the back muscles may be warranted but you need help with this - doing it willy nilly might just set your leg off. In the latter case you may benefit from specific training of these local muscles to stabilise the segment and this could result in reduced irritation of the nerve.


If you are getting a lot of loss of feeling and a lot of weakness in the lower leg due to the nerve being impinged upon then the spinal consultant can advise you on surgery options. However if it is just pain and you are not getting any (or just mild) sensory and strength changes then there isn't much evidence for surgery helping you - and you may well be advised to stay clear of the knife.

If there is a dynamic component to the behaviour of the sciatica (ie certain movements consistently make matters worse and others consistently improve matters) a manipulative physiotherapist or a physiotherapist who is trained in the McKenzie method may be worth consulting. Sometimes very specific exercises (not just extension exercises) can really help.

I wouldn't be too concerned about the comment from the radiologist is causing "the disc deformity to be permanent" It isn't just a matter of the disc. It is the fact that the disc has irritated the nerve root - setting off an inflammatory process. If the inflammatory process dies down with a bit of luck it may stop being a problem for you. Lots of us have structural deformities of the spine and most cause us now problem. You can have the disc bulge there and it not cause you problems. Likewise having the disc taken out surgically may not necessarily fix things.

These are specific issues that a good MSK physio can assess and help you with. Whether or not any of these options help you there is some overarching general advice that you definitely should be doing:

1. Keep active. Try not to limit you physical activity. In fact you should be thinking of increasing your physical activity. And a balanced programme of aerobic fitness along with strengthening can in the medium term be very helpful. If you are having trouble with such things as walking long distances due to increased pain get some advise from a physio about what specifically you can do to be more active - this can be an exercise in pacing - that is working out what you can manage but slowly increasing your output as you can do more. If one posture makes you uncomfortable then have a stretch in the opposite direction and keep on the move. Just avoid staying in one positions for too long. If you are better sitting with a support in your low back then use a support in your low back. You work out for yourself what works best. Bed rest is the worst thing you can do. Don't put yourself to bed. Instead opt for keeping moving with changes in posture.

2. Stop worrying. If you are anxious about the problem or concerned about making the pain or condition worse this has been shown to make matters worse, such as the pain and how you manage the problem. Again get some advice about how to manage this if you need to.

The final thing to say is generally sciatica does settle down and episodes of back pain come and go.

All the best with your management and recovery.

[jannie]

Thank you so much for your very informative and helpful reply. Its nice to get some constructive advice and reassurance asI seem to have had this condition for what seems like an age!

I am actually seeing a (NHS) consultant on 3rd August, not 10th as previously stated, so not too long to wait. I intend requesting a referral to a good physiotherarpist for the very reasons you state: manipulation, advice on strengthening back muscles, physical activity, etc. If that isn't possible for whatever reason I will self-fund as I definitely think a physio is the way to go - I wouldn't feel too comfortable seeing a chiropractor, for example.

Thankfully I haven't yet lost any feeling in the leg and hope to avoid any medical intervention, be it surgery or any form of injection as have read they don't necessarily improve things and can make matters worse.

With the pain under control I am managing to carry on pretty much as normal (just have to be careful lifting and bending) and know that the worse thing is to do nothing, especially sitting down or bed rest. Increasing active exercise does make sense and I guess, pending seeing a consultant, there is no harm in at least starting some regularly walking, starting with short distances and building up - I shall see how that goes.

I used to do a lot of high impact aerobic/step exercise in my "younger" days - This type of exercise is certainly out of the question at the moment but what about pilates, yoga or swimming?

Thank you again and I shall report back with, hopefully, some progress.

[markmiller]

Hi-

back pain and sciatica are two very common issues with people. Over 50% of people in the workplace have it. The main thing to do is identify which kind of postural distortion you have (kyphotic or lordotic) is any, and then go about getting a solid rehab program to strengthen weak muscles and stretch tight ones. This will enable you to get your muscles back in balance and allow your hips to naturally line up over your pelvis and stop crushing your discs which cause sciatica. usually, people with sciatica are in kyphosis, but you should know which you have specifically.

I have used a very easy to follow at home rehab program for the back which addresses all of this if you are interested:
S.M.S. Back Program

I found this program to be very effective and easy to use at home.

[gcoe]

Markmiller

This seems more abut flogging a program that costs money - I note you have also offered the same advise for those with ankle injuries. I think you should come clean about your ow interest in sales of these programs.

[markmiller]

No, I am not flogging anything. These are solid books and I recommend them to people, because they work. Not everyone can afford to go see a rehab specialist. if you can and they are good, then great. Otherwise, I think it is helpful to give people as much information as possible regarding a healthy recovery and let them decide what will work best for them.

[gcoe]

there is ample information for patients that is available and is actually evidence-based in the public domain - ie free. There is no need for them to spend money on commercial packages written by an author who is there to make money unless patients choose to do so. My understanding of this site is that we provide sound evidence in our advice where such evidence is available. In the case of low back pain with or without sciatica such information is available and it isn't necessary to purchase products based some unsubstantiated pet opinion about what is best.

[FizzyOHealth]

Sciatica is a type of referred pain which explain why the pain is felt elsewhere in the body.

It can be horribly painful but at least it is treatable.

Hope you feel better soon jannie

[jannie]

Thank you - I am hoping that the back specialist I am seeing on Tuesday will provide me with a long awaited diagnosis and a referral for some physiotherapy treatment. I will report back and let everyone know how I got on - It may just help others in a similar situation. Jannie

[jannie]

Just reporting back after my visit to the hospital today. Physio confirmed diagnosis as being compression of the nerve root by the bulging disc. Thankfully not to a degree that is causing weakness/loss of use in leg so surgery not an option (not that I would have wanted it anyway!). I was offered either a nerve root injection or physiotheryapy. I declined the injection and decided on the physio route first with a follow up hospital appointment in 6 months time. I think/hope I made the right decision!

Something that may help anyone else in a similar sitiation. If, like me, you are offered an NHS physio referral that has a long wait list (in my case 2 months), if you have not already been asked during the routine assessment/questions emphasise how much the pain is affecting your sleep - I am awake/up every 2 hours. This immediately qualified me for an urgent physio referral (1-2 weeks) so I am happy with that and will see how things go.

[gcoe]

All the best with the physio, Jannie. Hope you find it helpful.

[PhysioAdvisor]

Hi Jannie,

I would recommend seeing a physiotherapist particularly one who is trained in the McKenzie approach for appropriate treatment and exercises. Care needs to be taken clinically to ensure that your symptoms are arising from you bulging disc and not from your spondylolisthesis as treatment differs considerably.

You may also benefit from neural mobilising exercises, core stability exercises and eventually pilates exercises (usually once symptoms settle) and potentially some hydrotherapy. These exercises are best be taught by an experienced physiotherapist based on your clinical presentation.

Hope that helps and good luck,

[jannie]

I have taken on board the comments/suggestions from both physios, which is very much appreciated, thank you. I will take this info with me to my first physio session tomorrow morning. I will report back on progress/exercise suggestions. Jan

[orthoped]

Whatever be the status of your symptoms, but I strongly suggest you to keep monitoring your spondylolisthesis.

Spondylolisthesis is not a thing to toy around as it can cause severe pressure on the spinal cord.
MRI is not the modality to correctly give the grades of spondylolisthesis, since you are in a recumbent posture.

Standing lateral x-ray of the spine and flexion and extension views can give a better picture of the grade of spondylolisthesis.

Better beware cause it can progress to higher grades over a period of time.

[newscctv]

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