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    Old 01-09-2015, 04:14 AM   #1
    arihalli's Avatar
    Join Date: Oct 2006
    Location: upstate new york
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    arihalli HB User
    Can someone help me in translating this Dx?

    I rec'd this MRI 4/21/14

    FINDINGS: Transitional lumbrosacral segment is designated as partially lumbarized S1 vertebra to be consistent with the nomenclature used on prior MRI report. The conus medullaris is normal in contour and terminated at L2. There is upper lumbar dextroscoliosis and lower lumbar levoscoliosis as before.

    L3-L4: Disc bulge results in mild canal and mild bilateral neural foraminal narrowing.

    L4-5: Disc bulge and left posterolateral annular fissure are noted. There is mild ventral canal narrowing. Mild right greater than left neural foraminal narrowing. Facet arthropathy noted.

    L5-S1: Disc bulge and severe facet degenerative changes on the right side. Moderate right neural foraminal narrowing reidentified with contact of the exiting right L5 nerve root. Minimal ventral canal narrowing is seen.

    No paravertebral soft tissue abnormality is detected.

    Impression: Scoliosis and multilevel degenerative disc disease. There has been little interval change compared to the prior MRI of 2/21/07.

    I am 65yrs young. I was a very avid walker. I began getting more and more pain in my lower right side. Progressively so bad that I went to a neurologist about 6 months ago. The neurologist sent me to PT where they used decompression machine and 20 minutes of lower back rubbing. My problem only got worse.

    The neurologist sent me for 2 epidurals. Didn't do a darn thing.

    Now he is recommending 4-6hr operation to straighten my scoliosis in my back.

    I have asked him for a referral to accupunture but i refuse to let him do the surgery.

    Yet the pain is so intense its now 24/7. Naprosyn doesnt even touch it. And i refuse to use Oxycontin. I have a few questions if anyone can help.

    1) What does the MRI mean?
    2) Should I be getting a CT Scan? (it hasn't been done)
    3) For a second opinion --- should i go see another neurosurgeon or a spinal clinic?
    4) I am now on Medicare and fortunate enought to have the availability to go to the Cleveland Clinic or Mayo Clinic. I am in such bad pain i believe i will go there even if it is quite a long ride. What kind of MD in what department do you think i should ask for? Is it Orthopedic or Neurosurgeon. sorry about the length of this note. Thanks for any advice....

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    Old 01-09-2015, 09:12 AM   #2
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    Re: Can someone help me in translating this Dx?

    It is difficult to access the extent the scoliosis is causing your pain vs the disc issues you have that are causing nerve compression, in part because the report does not specify the amount of the curve, the size of the herniations, etc.

    If I read correctly, a neurologist has been directing your care so far, rather than a neurosurgeon. Is that correct? If so, my first suggestion is that you get an evaluation with a fellowship-trained orthopedic spine surgeon or a neurosurgeon whose practice is limited to the back and neck.

    If you have seen a neurosurgeon, I would suggest you see an orthopedic spine surgeon for another opinion. It is not necessary to go to a "Spine Clinic" to receive good just depends on what resources are available to you where you live. Depending on the extent of the scoliosis, you should look for someone who specializes in scoliosis or reconstructive spine surgery.

    Have you had scoliosis since you were young?

    The MRI report indicates you have a transitional vertebra. This means that there is an extra, or sixth lumbar vertebra that is partially attached to the sacrum. This happens in a small percentage of people during the formation of the spine during fetal development. This is mentioned so that any doctor examining you will be labeling any part of the lumbar spine accurately, especially useful if you have surgery to insure right level is operated upon!

    It also indicates that the curve of upper lumbar spine goes off to the right. The lower lumbar spine curves to the left, which is the same finding as was described in your previous MRI.

    There are degenerative changes in the lower lumbar discs. There is a bulge at L4-L5 which also has a tear through the annulus of the disc on the left rear or posterior side. There is a small amount of narrowing of the foramen at this level, worse on right side, than left, but present in both sides. There are two main areas where the nerves can become compressed...the central canal, and the neural foramen, which are little openings located at each vertebral level, that provide an exit for the nerves as they leave the spine to go out to the rest of the body. Any time there is a disc herniation where disc material extends beyond the disc space, or there is inflammation of tissue, there is a chance this will push into the foramina, causing spinal nerve irritation or compression. This can result in pain at the site of the compression or it can be felt at any point along the path of the nerve.

    Going along with the degeneration of the disc are arthritic type changes in the facet joints at this level. This often causes the joint to enlarge a bit, which tends to contribute to the narrowing of the foramen.

    I imagine most of your pain is coming from the issues at L5-S1 where the enlargement of the facet joint and is directly impacting the L5 spinal nerve on the right side. This can cause the type of pain that many think of as sciatic pain. The L5 nerve runs along the outside back of the leg, kind of wraps around to the front of the ankle and into the three middle toes of the foot. The changes to the facet is evaluated as "severe" so we can assume that there is almost no room for the nerves to function at this level. (There are 4 words used to describe the severity of an issue: minimal, mild, moderate and severe.). When something is severe, it generally means there is a need to decompress this nerve, usually done in a surgical process.

    I imagine this is why you were given PT using a decompression machine, an attempt to open up some space for the L5 nerve.

    Now, what to do? Conservative measures are always tried first, such as a course of PT, epidural injections, etc. When those fail surgery is the next step. What is unknown from just looking at the MRI report is how severe is the scoliosis and what impact does it have on your spine?

    The MRI is just one piece of the puzzle. The spine surgeon will look at the MRI and may see things that the radiologist missed. It will be correlated with the results of a physical exam, a basic neurological exam and after listening to a description of your symptoms and what impact this has on your life, a diagnosis and plan for treatment will be devised.

    If the scoliosis does not need to be surgically addressed, you might be able to get by with a discectomy or similar to decompress the L5 nerve. This is why it is important to get several opinions.

    Before I had my first lumbar surgery, my opinions ranged from a one level fusion to fusing up to six levels! Since the chances for success diminish with each added level, it is really important to do just the right amount of surgery...just what will be sufficient to get the job done. Also, you can always add on to a spine surgery, but you can never go back and undo what has been done.

    Acupuncture will do nothing other than to possibly relieve some of your pain for a short while. It will have no effect on the compressed L5 spinal nerve.

    Do your research and look for the most qualified spine surgeon that is available to you. Whether it is ortho spine or neuro is less important as their training is similar, but I would suggest getting an opinion from each because sometimes there is a difference in their approach.

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