I had an X-ray and MRI done 7 yrs ago which the outcome was my doctor told me I had a subluxation at my L5-S1. She told me to go to Physical Therapy and I did. After all of my sessions the Physical Therapist said there was nothing more he could do " I could look into surgery or utilize the techniques I learned and deal with the pain". I am in the military and chose the second option.
Now I am having horrible leg spasms, stabbing back pain, numbness/tingling down to my feet, electrical like pulses that go up back and radiate down my legs and up to my head. I explained to my current military physician assistant about the history of my MRI and x-ray years ago but he just said I probably had a pulled muscle. Since the first MRI I have dealt with the pain when it happens, but it never lasted for more than a day or two. I have been on pain meds now for the last month. My Physician Assistant had me do a Flexion x-ray (still waiting results) and refferred me to a chiropractor (waiting on refferral approval). At this point I am wondering if the chiropractor is the best option rather than being referred to an orthopedic specialist for a better answer as to how to treat me.
Here are the results from my current MRI which I had about a week ago. Can someone explain what it means or what they see. My physician assistant basically explained that his criteria to send me to an orthopedic specialist depens if the flexion x-ray shows instability (not sure what that means).
Findings: There are large pars defects at L5 bilaterally without marrow edema, consistent with nonacute pars defects. There is 14 mm of spondylolisthesis with anterior slippage of L5 upon S1. There is diffuse posterior bulging of the L5-S1 disc. There is relative spinal canal stenosis with the AP dimension of the spinal canal measuring 6 to 7 mm and proximal neural foaraminal stenosis bilaterally. There is some edema in the right facet.
At L4-L5, the disc is well maintained. At L3-L4 and L2-L3, the discs are well maintained. At L1-L2, there is anterior and posterior bulging of the disc. The conus is seen at L1 and appears normal.
Conclusion: Grade II spondylolisthesis at L5-S1 with nonacute pars defects, posterior disc bulge and stenosis L5-S1.
My X-Ray results were:
Findings: Frontal and lateral views of the lumbar spine obtained without prior for comparison demonstrate 2 cm, grade 3 anterolisthesis of L5-S1 and associated spondylolyses of L5. Remaining vertabral body height and alignment is preserved. Associated degenerative disc disease of L5-S1. Remaining disc spaces are preserved.
Impression: Grade 3 spondylolytic spondylolisthesis of L5-S1 which may be more specifically characterized by CT or MRI
Any info or sugesstions would be appreciated. Thanks.
Welcome to the board. My advice would be to avoid the chiropractor until you have seen a spine specialist...this can be either an orthopedic spine surgeon or a neurosurgeon whose practice is limited to the neck and back.
You can live with a spondylolisthesis for a long time without incident. Sometimes due to wear and tear or perhaps doing something new that uses or stresses different muscles, it can begin to cause pain. I made it into my 50s before mine began to cause problems.
The symptoms you are describing are fairly typical for a lower lumbar nerve compression. I will give you some basic info on the findings, but keep in mind we are not doctors...just fellow spine sufferers who share information and experiences.
Your spondylolisthesis at L5-S1 is fairly "bad." Mine was only Grade 1 and it was causing problems for me. When the vertebra slips over the top of the adjacent vertebra it can serve to limit space that is required for the exiting spinal nerve to function normally.
Spondylolisthesis is graded on a percentage with 1-25% being grade 1, 25-50% is grade 2, 50-75% slippeage is grade 3 and 75-100% is considered grade 4. The report indicates that you have a pars defect but indicates that it is "non-acute." I personally have not heard a pars defect described this way but I'm guessing that means it is not actively slipping at this time...but this is a guess unlike the other things I am describing....
Second, there are additional issues at this segment that also result in nerve compression. The disc is bulging toward the back of the spine. This is pushing into the central canal, putting pressure on the nerves that are contained within the canal (the cauda equina) and limiting it in size to 6-7mm (which is less than half as large as it should be normally). This "narrowing" of either the central canal or the foramen is called stenosis. It causes a passageway to narrow, which lessens the space for the spinal nerves to function, which results in nerve compression. If the nerve is badly compressed, it results in pain, numbness, etc. that you can feel anywhere along the path of the nerve. The L5 and S1 spinal nerves run down the back of the buttocks, leg, and go into the bottom of the foot and to the 3 middle toes (L5) and little toe (S1). (You can search for a "dermatome map" to see the path each nerve innervates).
The rest of the lumbar spine isn't too bad, with the exception of a bulging disc at L1-L2 which doesn't appear to be causing any issues.
If you suddenly develop issues with your bladder or bowel such as sudden incontinence, or you suddenly develop loss of muscle like in a drop foot, go to the emergency room as these are signs that you may be developing cauda equina syndrome. This needs to be diagnosed quickly so nerve damage does not become permanent.
Do what you can to be seen by a spine specialist as soon as you can. Don't go to a chiropractor as an improper adjustment could further damage the lower lumbar spine due to the spondy. You can find lots of good information online pertaining to lumbar spondylolisthesis, how to treat it, etc. Try to learn as much as you can about your issues so you will understand the doctor and will be able to converse with him/her about your options.
It is not an emergency situation, but if yours is grade 3 you may need to consider surgery at some point. Conservative treatments may be considered first...but usually when a spine specialist sees a Grade 3 listhesis, the patient usually hears the words "fusion."
I'm happy to answer your questions, or try to, anyway!
Update: This morning I woke up and when i got out of bed i practically fell to the floor. Afterwards, I could barely walk and so I called to make an appointment with my physician assistant. I have been walking with a cane that my wife has up until my appointment. My physician assistant basically said "why haven't I seen the chiropractor yet" and how long has my lose of strength in may legs been going on? I told him "I have told you my legs feel like gello, numb, tingling, spasms, etc...everytime I have seen you" not to mention the only reason he even had me do the MRI was because after I complained for about a week, I ended up falling on the stairs because my left leg gave out from underneath me; like it basically went to sleep. I explained that I hadnt received approval for the chiropractor yet and asked if it wouldnt be better to see an orthopedic specialist who could better treat me. He said "His doctor", one of physicians in the base clinic, said with the results of my x-ray/mri an ortho wouldnt even see me yet.
The end result of my appointment:
48 hr quarters (basically stay home today and tomorrow from work)
1 "four point walker"
more vicodin and tramadol
and finally a rushed (w/in the next 72hrs) appointment to see a pain management specialist
Also, my physician assistant said that the chiropractor or the pain management specialist would be better at reffer me to an ortho if they think it warrants it.
As I was typing the pain management office just called and i have an appointment tomorrow. I guess I will see what they have to say.
Does this PA have any back ground or training in orthopedics?? My lord....be sure to take the radiology report and the MRI with you to the appointment. You do not need pain management. You need an accurate diagnosis by someone who can see what is going on!!
Please read up on "cauda equina syndrome" so you are familiar with the symptoms in the event you have any turn for the worse...a grade 3 spondy should be taken seriously...particularly with the deteriorating conditions you are experiencing.
Good luck tomorrow and let us know what the PM doc has to say. Please insist on seeing a spine specialist.
So I went to the PM doctor today. First thing he asks me is why do I have a four point walker? I told him my PA prescribed it. He asked why. I explained to him about yesterday's incident and that today it is a little better but still very weak. The PM asked me about my back history. I explained everything I already wrote in my original post and said I had been managing my pain ever since the PT told me either surgery or deal with the pain through the techniques I learned in PT. The PM said "But you havent been managing the pain. You are on all these pain meds..vicodin, tramadol, tylenol 3 w/codeine". I explained that not until a month ago did I every need anything more than motrin and a little rest. Only when I had the incident of my right leg giving out did I start taking the meds and the pain has progressively gotten worse along with the spasms and weakness issues. He stopped me right then. He had me sit on the doctor table. He did a reflex test on my knees and ankles; they didnt really do anything when he tapped the tool on them, more so on my right side. He then did a strength test where he had me try to bring my leg forward, backward, outward, and inward and it was noticeably weaker on the right leg. He had me lie back on the table and he lifted my legs one at a time; w/the left leg I felt pain in my back at about 4-5 inches above the table; w/the right leg it didnt hurt until about a foot off the table and then he wiggled it up and down and i felt some pain. Then he had me roll on my side and touched my upper back and asked me if I could feel his cold hand; i could. Then he placed his hand on my rt buttocks, thight, and ankle and I could barely feel the cold. He then did a test with a pin and his finger where he asked me if it was him just touching me or if i felt a needle stick. On the left side i could notice the difference most of the time he said; but on the right they pretty much all felt like just pressure or nothing at all. He also had me try to flex my feet up while sitting and I could do the left foot but only half as much on the right foot. The PM then had me try to get up from table from the lying position, which hurt like heck he had to assist me.
That pretty much took about 15 minutes from when he walked in the room. His words after that were "You should not be seeing me, you need to be seen by a neurologist immediately". He said from my history, the results of my MRI and the test he did, I have nerve compression on the right side that needs to be addressed. I was kind of in shock at that point and I think he saw because he said "I am trying to give you a sense of urgency. This is no longer about quality of life that physical therapy or pain management can fix. I am making a referral to University of South Carolina, Columbia Neurosurgery". He told me to tell my military PA to do what they need to do to get it approved ASAP. The PM said he wants me to come back tomorrow to get an epidural injection for the pain in the meantime. My PA's nurse was actually at the PM's office for herself at the time and she overheard everything and said she would take the referral to my PA and it should be approved w/in the next 72hrs; hopefully sooner.
Now I am a little nervous about what options I might have to decide on if I have to have immediate surgery. With my spondylolisthesis, the stenosis, and the neuro issues, what type of options has anyone been given and what might be the best choice for me? I have read that the immediate issue would be some type of procedure to decompress the nerves. However, would they look at just doing that or fussion at the same time? If anyone has any procedures that I could research that would be helpful. I am already looking up ALIF, PLIF, Lumbar Decompression, Fussion because those are some things I have seen in regard to my situation. I want to make sure I know what is out there that could have the best outcome of less or no pain, recovery time, invasiveness, and risks.
I am a 36 male and have 5yrs left on active duty. I want to try to stay in and serve and avoid being medically discharged. However, I want to to it with the outcome that would allow me to be able to perform all of my duties effectively. Thanks in advance for any replies.
Last edited by HBar; 02-27-2013 at 12:47 PM.
Reason: the bad word filter turned a word to asterix
I'm sorry you have these issues, but am delighted that this doctor recognized your issues, did a thorough exam and was firm in referring you.
It is posible that you could have a smaller surgery to decompress the nerve or nerves...it will depend on "how bad" the spondylolisthesis is determined to be...but my guess is they will want to do a fusion.
Usually the type of fusion is determined by several things: where the problem is located, your body type, surgeon's preference, etc. A PLIF or in your case, if you will be able to continue on in the military, an ALIF/PLIF would probably be the best type of fusion unless the surgeon believes you could benefit from a fusion done with minimally invasive surgery.
Knowing you are in the military and knowing you have a Grade 2-3 spondy, I will be amazed if the surgeon suggests some procedure other than a fusion.
really sounds pretty advanced, and i always think a neurosurgeon is best. my spondy is a little over level 1, but with the DDD, the facet issues and bulging discs- i am looking at a spinal fusion this wednesday.
best of luck. no bodywork until you go to a neurosurgeon!
Hbar, wow, I am really sorry that your going through this, but I'm glad that the pain doctor has seen you and referred you to the neuro.
I don't really have any advice, as I haven't had a surgical consult yet, but I did want to tell you that I am praying for a you and your family and sending gentle hugs. My son is in the military so I have a special place in my heart for all soldiers.
God bless you and please keep us updated on how thing go with the surgeon, and Thank you for your service!