Disc Prolapse L5/S1

[Lurchie]

Hello all,


Apologies in advance for any misused/incorrect terminology. I'm just a sufferer.

I turned 22 in June but have been suffering from a disc prolapse which is causing Sciatica. I'm 6'2 and I weigh about 12 stones, I used to play a lot of football and frequent the gym, but not anymore.

This all happened in December 2009 and has been causing me problems everyday since. I had an MRI in April 2010 and the report I have typed out below...

Saggital scans from T11 - S2. Conus terminates at L1. Normal appearance of the visualised spinal cord. There is loss of normal lumbar lordosis. There is a right foraminal stenosis due to a broad based disc protrusion with right lateral component at... (Radiologist seems to have missed out where exactly this is on report).

Axial images


At L3/4 there is a diffuse disc bulge which is indenting the thecal sac but not causing any nerve root compression.


At L4/5 there is broad based disc bulge which is indenting the thecal sac. There is no nerve root compression demonstrated.
No spinal canal stenosis or foraminal stenosis at this level.


At L5/S1 there is a left paracentral disc protrusion and a left lateral component. This is causing compression of both the lateral recesses more so on the left side, affecting the transmitting S1 nerve roots bilaterally. This is also causing foraminal stenosis on the left with compression of the exiting left L5 nerve root. This is also causing about 50% spinal canal stenosis at this level.



Conclusion:

Broad based disc bulge with a left paracentral protrusion and a left lateral component at L5/S1 which is causing compression of both the S1 nerve roots and the left L5 nerve root.


There was an Addendum...


1) L5/S1 disc protrusion compressing both S1 and left L5 nerve root.
2) Left L5/S1 foraminal stenosis.

I'm having problems sitting, standing, walking etc. I have seen a musculoskeletal specialist who attempted manipulation but that was to no avail. I've also seen an Osteopath who thought I could do exercises to help the mobility and stengthen the area which I tried for a few months and then had to stop as the pain suddenly increased. I've also tried many alternative forms of therapy before I had my MRI and that also didn't work.


I can't quite put my finger on how this has happened but nevertheless I've been trying to live through it. Initially I carried on as normal, walking, driving, sitting, standing, jogging, running but then it got excruciatingly bad and have since dropped everything

I have been on a range of medication, some of them I still take, NSAID's - first started on Naproxen, then Diclofenac. Dihydrocodeine and Diazepam were also added. Amytriptyline and Gabepentin have been added recently and I've been told to take Paracetamol to help manage the pain too.

A few weeks ago the pain reached new heights, every position including laying flat caused pain, I took a trip to the hospital and was given morphine which helped. They since added Targinact Oxycodone/Naloxone - this works wonders for pain but not so much for your head. So I only take this if I am kicking and screaming, lol.


I saw a neurosurgeon who hopes to try a nerve root block and if that doesn't work will try a discectomy.


My questions are:

Can anybody explain to me briefly my problems? The surgeon and his team I saw were most unhelpful and I got made to feel a nuisance if I'm honest, I feel as if I'm the boy who cried wolf everywhere I go.


Should pain meds alleviate all the pain? How can I best manage the pain? As the pain is always there even with the meds, I've tried my best to deal with it but I've reached a point where I cannot do anything as sitting longer than 5 minutes is almost impossible.


Are there any specific exercises I can do to assist my recovery?


Nerve root block, is this a temporary measure?


Discectomy - what are the risks? and what other options do I have?



Any help or advice is greatly appreciated as I am ready to tear my hair out.


Thanks.

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[gcoe]

HI Lurchie

Sorry to hear you are having such a tough time of this. I understand this is not something you would expect at the the age of 22

My questions are:Can anybody explain to me briefly my problems? The surgeon and his team I saw were most unhelpful and I got made to feel a nuisance if I'm honest, I feel as if I'm the boy who cried wolf everywhere I go.

Sorry to hear this - you need to be able to communicate openly with the surgeon as he holds so much responsibility if you do undergo a procedure. I would be quite assertive about this. If you feel like you are not being listened to or are not getting the information you require don't pussy-foot around. Complain! Remember they are there to provide you with a service for which you are paying for - directly or indirectly. To be fair surgeons aren't always the best communicators - their moments of brilliance occur when the patient is complete out to it! Dealing with conscious patients isn't always their forte. So if they aren't being helpful let them know this - they don't always realise.

It sounds like you may have some disposition to disc disease, whether congenital or genetic. Having three levels of of faulty discs would suggest this.

At L5/S1 there is a left paracentral disc protrusion and a left lateral component. This is causing compression of both the lateral recesses more so on the left side, affecting the transmitting S1 nerve roots bilaterally. This is also causing foraminal stenosis on the left with compression of the exiting left L5 nerve root. This is also causing about 50% spinal canal stenosis at this level.

It is all about the disc putting pressure on the nerve roots where they exit. As it is affecting the S1 nerve roots on both sides and with the narrowing (stenosis within the canal at this level, this means there isn't much room to move. Are you getting symptoms in both legs or just left? So you get mechanical compression of the nerve roots and this irritates the delicate nerve structures causing inflammation - which in turn causes more compression and pain. The tissue responsible for the pain on the whole is one of the wrappings around the nerves called the dura. the dura is very sensitive to pain in order to protect the nerve from harm. The nerve itself is insensitive to pain but when the nerves are compressed you get a loss of function to the area in the leg that the nerve services: muscle weakness and loss of sensation. Pins and needles are common and that is when the sensation is being affected but is still partially intact.

Should pain meds alleviate all the pain? How can I best manage the pain? As the pain is always there even with the meds, I've tried my best to deal with it but I've reached a point where I cannot do anything as sitting longer than 5 minutes is almost impossible.

You clearly aren't coping with the pain and you are on quite a cocktail of medications. As this has been going on for 8 months now the pain has become chronic. Taking opioid preparations isn't the best at this stage but you need to get advice from a good Dr on this. Pain medication is just one avenue. It might be worth considering other ways in addtion to the medications. Cognitive Behavioral therapy - a well established psychological intervention has been shown to be helpful with managing chronic back pain. this is not to say that back pain and sciatica are psychological problems but pain and how it is managed is very amenable to sound psychological help. And pain can also be depressing and can make you aversive to activities you anticipate will make you sore.

Getting help from a pain team is often the best way to go: pain specialist, OT, PT Psychologist. From a physical therapy point of view I would be quite concerned about your difficulty with exercising as you were obviously fit before and now have really blobbed out. Not managing sitting for more than 5 mins is very restrictive so if I was your PT I would want to address these issues and support you through getting to be as active as you can manage. Loss of fitness is bad for back pain and makes matters worse.

Are there any specific exercises I can do to assist my recovery?

Given that the pain is quite probably quite irritable I think you need to go and see someone rather than giving exs over the net. One approach that may be worth trying is a PT that uses the McKenzie method- If it isn't helpful the therapist should be able to let you know from the start or you will find out quite quickly - you should get immediate reduction in symptoms if it is helpful. However there are other approaches

Nerve root block, is this a temporary measure?

Yes and no. The block usually consists of an anaesthetic (temporary) and a steroid (antiinflammatory that can break the irritative cycle thereby potentially being long term.)

Discectomy - what are the risks? and what other options do I have?

Best to talk to the surgeon about discectomy risks. In addition to the risks the need to achieve some decompression is important to consider. If you have a lot of weakness and numbness then it may be the best option. If it is mainly pain and not much weakness or numbness then give your age I would definitely want to consider other options.

Actually, one effective treatment is the activation program - that is basically a full on fitness programme - there is evidence that this may reduce the problem and even reduce the need for surgery. However - as I said - you would need to get support with the pain relief side of things as this can be daunting. So the programme must be supervised and often works best with a multidisciplinary approach.

What is your line of work?

[PhysioAdvisor]

I agree with the previous reply and would recommend seeing a physiotherapist who is trained in the McKenzie Approach. This should primarily comprise of specific exercises designed to push your bulging discs back into their original position (commonly back arches) and avoidance of activities that are likely to aggravate your disc bulge (commonly sitting, bending and lifting).

Hope that helps and good luck,

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[dhdemon]

Hi Lurchie.
Iam new the forums and just stumbled on your post. Your post reads just like the past 2 years of my life. Iam a long term sufferer of lower back and the last month it has finally come to a end I hope.
Like you I played football,rugby and cycled for most of my life. 2 years ago the pain came to a point where my wife saw her first grown man cry with pain. My doctor put it down to sciatica and prescribed pain-killers,anti-inflamtories and physio, this has got me through the past 2 years but things got worse over the past month. I went numb down my left leg and around my groin area, I visited a differnt doctor who told me to go directly to my local A&E where I had a x-ray and was told it was possible I had Cauda equine syndrome which is a very serious condition. Having been messed about for another 2 weeks by my local hospital and being re-diaognosd with sciatica my GP referred me to a neurosugeon. I had a MRI scan on wed 6th april and on sat 9th april I had discectomy on my L5/S1. The surgeon said I was very lucky I came when I did on I could have lost all bladder function and maybe paralasis of my left leg. I have been home now for 2 days and it has amzed me how go surgery has been for me, I was up and walking within 8 hours of the op and I can already walk about a half mile unaided. I have been told by my physio that it will be at least 3-4 months till Iam fully fit and able to get back to normal.

I didnt really have a choice about the surgery but Iam so glad its done. Its the first time in years my back is pain free, I have read my reports on surgery good or bad but I looked at it as everybody is differant. If you want to know any more feel free to ask.

[gcoe]

Surgery has a place in certain cases of disc prolapse and particularly at the very severe end of matters and where you have spinal cord or cauda equina symptoms (frank paralysis in the legs, loss of bladder or bowel control, loss of sensation in the "saddle" area between e thighs. And ano-genital area) it becomes essential. Dhdemon you obviously fitted this profile.However in the majoriy of disc prolapses surgery is often disappointing, failing to relieve the symptoms and can even make matters worse in the long term. Generally surgeons who work in the best interests of their patients are very cautious and consevative about operating and those who are "knife happy" should be avoided. There are a number of therapeutic approaches that have research evidence for helping that should be tried first and surgery should really be the last resort unless as I said you have direct encroachment on the spinal cord or cauda equina.

One major problem with back pain is that most of the time we don't know for sure what is causing the pain. Having the presence of a disc bulge or prolapse isn't necessarily the cause of the pain -it just happens to be easily imaged over other poblems. prolapses are very common in people with no back symptoms. So just having a prolapse in the presnce of pain may not be the cause. there often has t be quite a lot of detective work to be sure if that a bulge or a prolapse really is the culprit. Back pain is not straight forward and remains not that easy to treat much of the time -probably one of the reason why there are so many treatments on the market. A case of let the buyer beware

[hasanali]

Hi There my name is Hasan Ali and im 23.
i have been suffering from back pain for almost 2 years now last from 3 or 4 weeks i have pain in my right leg i went to the doc he said to me to have a MRI.
what MRI says is.'' there are multilevel areas of disc is a region of disc herniation at L45 and L5S1 region with the disc at L45 having a central and bilateral para central component with bilateral neural tissue compression.
the disc at L5S1 is having central and right sided component with right sided compression to nerve root.
now doc suggest me to go down for a surgery but i don't wanna do that i just want to have your opinion what should i do in this situation plz guide me further
thanksssss