L4-L5 and L5-S1-help needed

[customsoda]

Hi - I really need some advice. My back has been injured several times over the past 20 years. I have been unable to get a reaonable level of pain relief from anything. My orthopaedic surgeon in London Ontario says I am not a candidate for disc replacement. I sent my MRI and x-rays to Zeegers at AlphaKlinic but never received a reply. I'm afraid this means he does not want to help me/can't help me either. Does anyone have some suggestions? The spasms drop me to the ground and my day is over shortly after it begins.

My most recent MRI shows "Lumbar Spine MR!
Reason for Exam Ongoing LBP, BIL SCIATICA

Read
CLINICAL INDICATION: Severe low back pain. Bilateral sciatica. Previous discectomy 1994.

TECHNIQUE: Axial and sagittal T1 and T2 imaging

FINDINGS: Compared to the previous lumbar spine MR from March 2007 there has been interval worsening at L4-L5. Normal alignment. Distal cord demonstrates normal size, contour, and signal. Conus medullaris is in normal position at T12. degenerative disc signal loss at L4-L5 and L5-S1. Moderate to severe disc space narrowing at L5-S1.

Small T12, L2, and L4 intravertebral hemangiomas. Relative stable severe Modic Type II degenerative endplate change (fat infiltration) at L4-L5 and L5-S1.

No paraspinal abnormality seen.

L4-L5: Previous left laminotomy and ligamentum flavum resection. Moderate facet disease. Increased moderate annular disc bulge with a superimposed NEW large left paracentral inferior disc extrusion. Extrusion extending to the mid L5 level and appears contiguous to the native disc. Cannot rule out a sequestered component however,. Extrusion is causing severe compression of the L5 nerve root. There is indentation of the thecal sac with some posterior displacement of the left S1 nerve root. Mild central canal stenosis.

L5-S1: Moderate facet disease. Stable moderate disc osteophyte complex. Previous left laminectomy and ligamentum flavum resection. Disc osteophyte complexes is causing mass effect on the left traversing S1 nerve root. Moderate bilateral foraminal stenosis.

IMPRESSION:

1. Moderate L4-L5 annular disc bulge which has increased in size since the previous study. At this level there is a new large left paracentral inferior disc extrusion compressing the left L5 nerve root and causing posterior S1 displacement. This could explain left L5 or S1 neuropathy.
2. 2. Moderate disc osteophyte complex at L5-S1 causing mass effect on the left S1 nerve root. This may be contributing to or causing left sciatica.
3. 3. Moderate to severe degenerative disc disease at L4-L5 and L5-S1."

[Harrison]

Sorry for the late reply. If you were disqualified for facet disease, why would you want to discount the importance of this finding? This is serious stuff which we've discussed many times on this forum...

[annapurna]

To add to what Richard has said, you sound like a candidate for fusion followed by monitoring L3-4 to ensure that the possibility of adjacent level degeneration doesn't catch you unaware. Facet arthroplasty is still in its infancy and might be a possibility if you could hold out for a year or more but it doesn't sound like you can.

[customsoda]

I am aware it is serious stuff and have spent a lot of time reading messages here and other places trying to learn about my condition. My Ontario doctoris allowed by OHIP to do only 1 level of disc replacement, and stated OHIP allows him to do only 15 per year" and picks only the most perfect candidates. Our medical system in Ontario is only great if all you need is an annual checkup. We wait months for MRIs and 6 - 8 months to see a specialist. What I have been trying to discover is if anyone else has the skill/knowledge/ability to do something for me, whether it is surgical or pain management. After I sent the written copy of my MRI and my questionnaire to Dr. Zeegers, he called and said the case was complex and asked me to send x-rays and MRI films which I did. I hoped to get a 2nd opinion from him but can't even get a response. I don't want surgery that would not help or make me worse. I just want someone to help me find a way to decrease my pain.

[annapurna]

Practically, you're going need something like discograms to confirm or deny what fraction of your pain is coming from your disks. You'll also need facet diagnostic injections to be 100% sure, but be warned that if your disk pain is dominant, you might not even be able to sense pain from your facets until the disks are fixed. Gating theory says that the major pain source tends to be the only "signal" that gets dealt with as pain; it's why stamping on your toe to eliminate a headache actually works. It's also why some people discover that they have painful facets only after ADR.

You should have surgical options available to you. They sound like they'll be limited but should still help your pain. I can't recommend for or against them as that is a very personal decision and entirely your own to make but the risks of various options have been discussed here and elsewhere. Pain management options should also be available and have kept people functional even when their disks were self-fusing. I'm also not recommending for or against those options but rest assured that, if you're willing to pusue the "big guns," somebody can come up with help for you.

[customsoda]

Thank you Annapurna. It is easier to manage when there is at least a little bit of hope that someone can help with the pain if I just keep looking.

[Rosie]

I lived in Ontario/Toronto and had my surgery done in the country.

PM if you wish to communicate.

Take care

[ZorroSF]

This seems confusing.
You have a disc bulge at L4L5 that is putting pressure on the L5 nerve root? Both levels are degenerated.

seems like a fusion at L5S1 and maybe ADR at L4L5 but there no specific info about the facet degeration at L4L5. you need those facets tested. ADR will put a great strain on those facets at L4L5 if you go through with it. So much so that ADR at L4L5 wont' be enough. You would also need a posterior device to prevent stenosis at that level.

The muscle spasms are from the disc rubbing up against that nerve root. That's a horrible place to be cause I've been there. I'd schedule an epidural on that nerve root ASAP. Then when that takes hold from giving you spasms I'd start looking into facet blocks for temp reasons.


I suggest getting three surgeons' opinions. IF you didn't get a reply from Zeegers I'd keep following up with his office.