I know we're all laymen here and none of this is reliable medical advice, but sharing information and decoding the medical language seems to be the first place to start now that I have an official MRI report. T, your description of your own symptoms in the past match what I'm experiencing now. Your contribution has clearly been extensive and surely helpful to many people. (Tried to PM you but system won't allow it, hence the overly forward friend request.)
I just had a MRI yesterday. Here's the beef:
"FINDINGS: There is approximately 10 mm of anterolisthesis of L5 on S1. There are bilateral pars interarticularis defects at the L5 level. Endplate marrow change is seen at L5-S1. The remainder of the lumbar segments are normally aligned. The vertebral body heights are maintained, aside from some probable degenerative height loss at L5. The conus terminates normally.
Review of the axial disk spaces is as follows:
L3-L4: Mild disk bulging, but no central or foraminal stenosis.
L4-L5: Central disk protrusion, with disk material extending inferiorly into the left lateral recess. Disk material appears to encroach on the traversing L5 root. The exiting L4 roots do not appear significantly compromised. There is impression of disk material on the ventral thecal sac.
L5-S1: Marked widening of the canal in the setting of the anterolisthesis. There is broad-based uncovering of the disk. These findings result in high-grade narrowing of the bilateral neural foramina. Traversing S1 roots appear grossly intact.
The included paravertebral soft tissues do not demonstrate any significant abnormality. There is a slight lumbar levoscoliosis.
1. Approximately 10 mm of anterolisthesis at L5-S1 in the setting of bilateral pars interarticularis defects. As a result of the listhesis and the uncovering of the disk, there is high-grade narrowing of the bilateral L5-S1 neural foramina. Correlation with radiculopathy at this level is advised.
2. Predominantly central disk protrusion at L4-L5, with some disk material extending into the left lateral recess. Can correspond with a left-sided radiculopathy, particularly at L5 distribution, given that the exiting left L4 root appears to be intact."
So it's not good to be me at the moment. I have good days and bad, with acute symptoms in the past 6 weeks. I know I've had 2+ spondylesthesis for 20 years, probably more, but that's when I first heard the word. Up until now, I've been able to deal with occasional discomfort and still live a normal and very active life.
Specifically, what does "Correlation with radiculopathy at this level is advised" mean? My neurological symptoms are consistent with diagrams of L5-S1 sciatica down to the front of my ankle but no toe involvement to speak of. Like T, thank God I can sit and be ok lying down for the most part, but I do get the "darts" sometimes turning over in the night.
I'm encouraged that from my reading, it appears stenosis isn't a factor as much as the pure mechanical reduction in the forimina area(s). But I don't see anything other than a surgical solution on the horizon. Hope I'm wrong, but I'm afraid not.
So any and all advice on where to go from here would be great to receive! Travel is not a limitation (job bennie), so quality is job 1, to pirate a slogan.
Your issues sound similar to mine, although I think your spondylolisthesis is greater than mine was.
1. Approximately 10 mm of anterolisthesis at L5-S1 in the setting of bilateral pars interarticularis defects. As a result of the listhesis and the uncovering of the disk, there is high-grade narrowing of the bilateral L5-S1 neural foramina. Correlation with radiculopathy at this level is advised.[/B]
This is the level of your spondylolisthesis....The foramina are the openings connected to each vertebral segment that allow the spinal nerves at this level to exit the spine. They can become "clogged" due to a variety of things happening, such as a disc herniation, facet arthritis, producing bone spurs, etc. In your case the result of your anterolisthesis is that the foramen on both sides are being affected and are narrowed. The radiologist suggests that the examining doctor check your symptoms to see if there is a relationship between the radiculopathy you are experiencing and the issues caused by the spondylolisthesis. Is the foraminal stenosis causing your leg pain?? (High grade could also be called "at the upper range" or I believe, "severe.")
As you know, anything that occurs in the spine that interferes with those spinal nerves usually ends up causing pain. You have the foraminal stenosis at L5-S1 and in the next level up, L4-L5, something similar is going on but this time it is the disc between those two vertebrae that is pushing against the passageway, "Left lateral recess." The disc material has come out of the disc and is pushing up against the traversing L5 nerve root. This disc material is also pressing on one side of the thecal sac, which is the tough membrane that surrounds the central canal nerves.
The report goes on to indicate that the L4 nerve roots, as they exit the spine, do not appear to be affected by this disc protrusion.
The fact that you still have good days indicate that the nerve compression is not as bad as it could be!
The problem with having spondylolisthesis is that once it starts causing problems, and is causing one or more nerves to be irritated or compressed, no amount of conservative treatment is going to be of much use. The only solution is to stabilize this segment so it is not able to move...and for now, that is done with fusion.
I don't remember if you have consulted with a spine surgeon yet? That would be your next step. It would be to your advantage to locate a well-trained spine surgeon in your area rather than having to travel to find treatment. I went several places initially while I was convincing myself that my diagnosis was correct, but I elected to have surgery locally because his credentials were just as good and I knew I would want more attention from and interaction with the surgeon beyond just meeting him once prior to the surgery, and then maybe seeing him a couple times after for a check. I have probably seen twenty spine surgeons within about 100 miles and am lucky that I live in an area with very good medical care, so I didn't feel the need to travel....but I would if I had an unusual problem that required more technical expertise that my surgeon had.
Hope this helps. If I neglected some question you had, let me know, and I'll try to answer it.
I noticed your question to me about the source of my pain on another post and will answer you here...
I initially had a one level fusion at L4-L5 that was to resolve my leg pain that was thought to be caused by my spondylolisthesis at this level. Surgery went well, I fused, etc. but six months later, it was clear to me that nothing had changed...and it wasn't just a matter of giving the nerves time to heal. I didn't feel a bit different than I had prior to the fusion.
The reason it took two years was because I couldn't convince anyone that there was something wrong with me that had a potential solution. My surgeon and the Pain management doctor kept insisting that my new MRI looked good and there was no nerve compression...and that my pain must be from scar tissue or because the nerve was permanently damaged.
I refused to believe this because the symptoms were just the same...and the pain would go away when I got off my feet. It seemed logical to me that if the nerve itself were damaged, I would have pain all the time, or at least it wouldn't come in such predictable patterns.
They wanted me to get a spinal cord stimulator and they wanted to just treat the pain. I wanted to know why I was still in pain, and I refused to have the trial for the SCS.
I switched surgeons and found one that was a bit more willing to help me explore my options. And that's what I did. It turned out to be a non-medical person who figured out what he suspected was causing my pain...then I had to convince my surgeon, which took awhile...and I had a whole lots of diagnostic nerve blocks along the way. Finally surgeon was convinced and scheduled me for a 3 level fusion...got to within 12 hours of the date and my insurance carrier refused to cover the cost of the surgery. So that slowed me down for a couple more months while I appealed the decision and won my case. So two years ago yesterday, I had the surgery.
Oddly enough, when he got in there, expecting the worst problems to be at l5-S1, he discovered that the facet joints at L3 were worn away to tiny little nubs. This was allowing my spine to move around in all kinds of ways nature had not intended. He ended up having to reconstruct that segment of my spine. Then the hardware from the earlier surgery was not compatible with the new hardware, so that had to be removed....then he could complete the fusion, put in the screws and connected the whole mess with two long rods...so I am now fused from L3 to S1. He had promised me prior to surgery that he would clean out any and everything that looked like it might possibly be touching a nerve...and he did...including some scar tissue from the first fusion.
On the 4th day my leg pain vanished, and, I was pain-free for the first time in about seven years. Even though I still am holding my breathe, it has not returned. I have spent the last two years slowly rehabilitating -- going VERY slowly so as not to irritate the sciatic nerves. I am actually going to see my surgeon on Monday for my "two year check-up."
Well Teteri, I was hoping you'd give me a good response, but this was excellent! No wonder you're the queen if this site. Thanks for your time not just for me but who knows how many "lurkers" out there.
Location is ME summer and S. FL winter. Trying to pull off the snowbird thing. Boston has the reputation of being a great place to get sick, and Beth Israel, Brigham and Women's plus MGH have good press and accolades. In Miami there are some good names too. I haven't seen any specialist yet.
You mention stenosis. I didn't see that and interpreted the report to indicate that the fwd shifting of the vertebra or -ae was responsible for the constriction around the nerves. I poured over my MRI pictures but probably seeing a model would help me visualize that better.
Fortunately it appears only S1-L5 and L5-L4 need attention and likely fusion for S1 at a minimum. Not sure about L4-5 but will seek advice. One stop shopping is appealing. Is there any advantage to disk repair over a fusion there?
Good job fighting the system! It's nice being right but sucks to have to go through the appeal process.
Finally, after over a month of painful standing and walking, I found exhilarating freedom in bicycling! I can get a great pain free workout and roam the countryside which is enormously liberating mentally as well as giving me my fix for exercise. Only bummer is my dog is too old to keep up with me anymore.
So for those who have upright pain that goes away sitting, look into possibly biking. Hopefully it's not contraindicated, because it's all I have to look forward to physically now.
Thanks again for any and all guidance as I begin this process. At least the MRI is validating. I see lots of views of this post. Presumably most people with successful outcomes just move on, but any information anyone wants to share ill gladly listen to with appreciation.
You are much too kind! Personally, I would choose Boston over Miami any day. There is a member on here who primarily posts on the Spinal Cord disorders board named Jenny who has a wonderful surgeon in Boston. She primarily has cervical issues, but he recently did some lumbar surgery on her. I thought she'd need a fusion, but he was able to decompress everything without it. Jenny's problems have been on the unique side of "usual and customary" and this surgeon seems to come up with creative ways to address her problems. I can't remember his name, but I'll get it from Jenny so you can check into him.
The word stenosis is not specifically used in your report, but stenosis is just a name to describe a narrowing...either in the central canal or in the neuro-foraminal openings. You will note you have this at both levels. [B]As a result of the listhesis and the uncovering of the disk, there is high-grade narrowing of the bilateral L5-S1 neural foramina. [/B]
And at L4-L5, there is a disc herniation...but it is the disc matter coming out of the disc and going into the lateral recess that is taking up space that should be open so the nerves can pass out to the body without getting "squished." The lateral recess is narrowed due to the disc material.
Stenosis would probably not be the primary diagnosis or what would go on the sheet sent off to the insurance carrier...spondylolisthesis would probably be the primary diagnosis.
I agree with you. I don't think there would be a need for a two level fusion...I would think the L4-L5 herniation could just be cleaned up while the surgeon is in there doing the fusion on L5-S1.
I am glad you are able to bike. It is so important to keep physically active. That was one point I made in my appeal to the insurance carrier...that my over-all health would suffer if I was unable to have the fusion...I was at the point where I could only stand about a minute and I was driving to the mailbox at the end of my driveway to get the mail, as I couldn't walk more than about 20 steps before needing to sit. Be sure to keep it up. It really helps to be in good shape prior to having surgery. I think that might be one reason my second fusion was easier than the first in terms of being able to reposition my body in bed, move my body, in general. I'd had lots of PT in between the surgeries and probably was stronger than I was prior to the first surgery.
Hi Cloudchsr....Teri asked me to come on and give you my surgeon's name in Boston....he is world class according to the malpractice attorney I had check him out.
It's Dr. Eric J. Woodard and he's at New England Baptist Hospital in the south end of Boston, near Brigham and Women's where he used to be chief of spinal surgery. He's chief of neurosurgery at NEBH(smaller private hospital so no "on-calls").
He's done 3 spine surgeries on me....2 cervical and 1 lumbar and at 10 weeks post-op, I hardly know I had surgery except I've gotten all the feeling back in my legs and feet. I could barely drive my feet were so numb....couldn't feel the gas pedal. I'll be driving to Boston by myself when I have my 3 month check-up. With the cervical, I went from partially paralyzed due to a broken neck to now being able to hold my grandkids and do whatever I want within reason(I am 60). Not bad for someone he thought would never get her left arm back....but the range of motion is 100% and strength is about 95%. I credit his surgery.
As with all "hotshot" docs, you have to have your doc send a request for a consult with a recent MRI(in CD form) or report and if he thinks he can help you, you'll be called with an appointment. It can take up to 6 months to be seen but if he thinks you need to be in sooner, you'll be in sooner. He's good about that.
As one doc told me...he's does operations that no one else does and has the most amazing touch during surgery. I'm sold......he's pulled out some amazing stuff with my spine.
That's [I]exactly[/I] the kind of person I want to have operating on me. I take my job just as seriously when I'm working, so expecting the same in return seems reasonable. There is no room for error here.
The 6 month wait part doesn't sound like much fun, but maybe he'd think my situation is significant enough to move up or recommend someone similarly capable who's more available. Honestly, I don't think my back issue will be nearly as complex to correct as what you went through, but with potentially lifelong consequences, only the best will do. Maybe your dr specializes in the difficult cases and someone who routinely does less advanced work would be better for me. An endorsement from someone stellar might be the best i can do
But the description of his fine touch is very appealing.
Probably the subject for another thread is how to check out doctors. I haven't looked into that yet, but it sounds like you have done thorough research.
Again, thanks for the name and I will set up the referral as soon as I can get a call returned from my PCP (grrrrrrr!)
Hi George.....he does have a brand new doc that he trained and hired who would be more available. His name is Dr. Nicholas Marcotte.....did his neurosurgical training at the Neurological Institute in Montreal(one of the best) and did his spine fellowship with Dr. Woodard.......Woodard was so impressed by his skill he hired him....so he has to be very good. He did most of my lumbar surgery 10 weeks ago and I knew that surgery had worked within 6 hours of waking up......pretty impressive. So if Woodard is too long a wait, ask about Dr. Marcotte. If he needs help, Woodard assists him.
I'll see you in the waiting room!
The Following User Says Thank You to jennybyc For This Useful Post: Cloudchsr (06-06-2012)
I saw name of "le Docteur" on their web page and assumed the same thing, that presumably Dr. Woodard would only take on a similarly competent associate. He was the one who did your last surgery then?
At this point I am concerned about potentially worsening neurological conditions, so I feel a moderate sense of urgency to get something scheduled sooner rather than later. Yesterday was a pretty good day, but today not so much, and the instability is unsettling as I don't know what might come next.
Hopefully Teri's tuned in too, as I have an odd symptom that I think is related she might have heard of. On my right knee, I have what feels like a neurological hypersensitivity. If I push with a finger on the middle, right below the knee cap, I get an intense stabbing and burning sensation about 1-2 inches to the right of the spot I push on. My knee otherwise works perfectly, so I'm assuming and hoping this is all related to a spinal nerve compression. At least this is something I can work around, as opposed to the standing and walking limitation from sciatic irritation.
I'm going to call Dr. Woodard next. I've also checked in with the MGH spinal center. They have a very extensive website, what appear to be immensely qualified surgeons, and an evaluation center headed by an older but obviously well connected Dr. See
and click on his name, upper right for a CV. Presumably he can steer me to someone good among the Harvard associate professors there. If you're curious for more, check out Dr Borges' site with a surgery movie here:
I'm not exactly sure what he's working on, but it appears very delicate.
Both of you are far more seasoned patients than I am, so I'm a bit anxious about my likely surgery. Honestly, your stuff presumably was much farther up the difficulty scale than what I expect mine will be, but I still want a top grade team. Fortunately, this isn't an emergency surgery at this point and I have the luxury of being able to find someone I'm comfortable with.
I'll keep you and other observers posted with my progress, and again, thanks so much for your help this far.
As for meeting Jenny in the dr's waiting room, shouldn't you be out pole vaulting somewhere instead by now??? My hope is this will be a one time good deal, an easy surgery with a quick recovery and no repeat visits, and back to my active life as it was asap! But I will look for your lucky chair
George, what you are describing with your knee sounds like a case of bursitis. There is a big bursa under the patellar tendon in the front of the knee below the kneecap that can blow up and hurt like the dickens. And unfortunately, it's one that can't be injected for relief. Use ice packs on it to reduce swelling and take any kind of anti-inflammatory you want...ibuprofen, Aleve, whatever. And whatever you do....don't kneel on it! On top of spine issues, I've had 14 knee surgeries and both have been replaced. Had bursitis there many times.
I don't know for sure who did most of my lumbar surgery except I got a bill from Marcotte and not Woodard. I'll make a long story short....the day of my surgery we got caught behind a huge accident on the way to the hospital. I was the 7:45am surgery and we left CT at 3:15am...only to be the 3rd car behind a 3 tractor trailer accident with a 1000gal diesel spill.....so the highway was closed and we couldn't move as we were right up front. 3 hours later, we got on our way and reached Boston at 8:45am. I thought they'd cancel the surgery but instead, did me as the last surgery of the day at 5:30pm. Since Woodard had already been in surgery all day, I think he probably was there but let Marcotte do the surgery along with his latest fellow. But I do know he was checking in on it. I really don't care...they did the surgery. I was sure I'd have to wait another 4-6 weeks. Pretty nice of them to accommodate me.
Yeah, I learned fast not to kneel on it! Actually if I start kneeling on the outside and roll in, it's ok but in and rolling out, not good. It feels like a red hot nail, although I've never experienced that.
14 surgeries??? Your insurance company must love you!
I have a reasonably good friend who's an orthopod so I'll see him next week. I'll ask him about the knee too. So much for aging gracefully...