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  • What to ask the neurosurgeon??

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    Old 01-09-2014, 07:40 PM   #1
    Fr Bill
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    What to ask the neurosurgeon??

    Newbie here, hoping to get some coaching before my appointment with a neurosurgeon next week.

    Presenting symptoms: sharp, flashing, “sheets” of pain through both buttocks. Most unusual stuff I've ever experienced! Sharp pains in muscles at top of thighs, midway between the front and side of thigh. Weakness of the right leg, dull ache in right calf. My gait has gone wonky – I can't stride at all; I sort of waddle, like Popeye. I've fallen twice, once on a completely flat, unobstructed surface. I expect it's because I've spent six decades developing muscle memory for walking, and now what I expect of my legs isn't happening any longer.

    Diagnositcs:

    GP ordered an xray and sent me to an ortho man in the provider group. The xray radiologist didn't see anything unusual, beyond what he characterized in the findings as “mild” bone spurring. The ortho man ordered an MRI.

    In light of the MRI findings (which I don't begin to understand yet), I was disappointed in the ortho doc's plan going forward – essentially pain management and PT.

    I've copied the MRI radiologist's findings below. I will see a neurosurgeon next week to discuss these findings. As this is an entirely new area of medicine for me, I'd be grateful for any coaching more experienced patients/caregivers could offer to me concerning issues, ideas, questions, etc. that I should raise with the neurosurgeon.

    Honestly, I'm not eager for any kind of back surgery. On the other hand, I'm not eager to spend the residue of my life managing pain and advancing immobility IF those can be forestalled or avoided by surgical intervention now. My health is reasonably good now; in ten years, perhaps it won't be. Someone somewhere said “Carpe diem!” and I'm minded to consider that advice seriously.

    So, what would you pester the neurosurgeon about? That business in the findings about a synovial cyst looks serious. But, I have no sense, really, for any of the findings – whether they're serious or not.

    Anyone who's gone down this or similar paths, I'm all ears.

    Here's the MRI findings/impression:


    Findings:

    Vertebral body height are will-maintained. Scattered vertebral body hemangiomas, largest of which is anteriorly situated within the L3 vertebral body.

    Decrease in expected lumbar lordosis. Background of congenitally narrowed spinal canal, most significant at the L1 level. Mild dextroconvex scoliotic curvature.

    Multilevel disc space height loss greatest at the L4-L5 level asymmetric to the left, and less so at the T10-T11 level.

    Conus is unremarkable in caliber and signal intensity and terminates at the upper L1 level.

    T10-T11: Minimal disc bulge without spinal canal or neural foraminal stenosis.

    L2-L3: Asymmetric left disc bulge with minimal bilateral neural foraminal stenosis. Mild congenital spinal canal stenosis.

    L3-L4: Moderate ligamentum flavum hypertrophy and facet arthropathy with a circumferential disc bulge asymmetric to the right. Small superimposed foraminal disc protrusion with disc material that extends into the anterior-inferior aspect of the right neural foramina. The disc lies in near proximity to the exiting right L3 nerve root sleeve. 9x3 mm synovial cyst with asymmetric to the right disc bulge results in encroachment of the right subarticular recess and possible compression of the descending right L4 nerve root sleeve. Resultant mild to moderate spinal canal stenosis asymmetric to the right. Left neural foramen is widely patent.

    L4-L5: Circumferential disc osteophyte complex with moderate left and mild right facet arthrosis. Superimposed millimetric inferior left foraminal disc protrusion results in mild left greater than right neural foraminal stenosis. There is also encroachment on the left subarticular recess.

    L6-S1: Congenital spinal canal narrowing without notable stenosis or neural foraminal stenosis.

    Impression:

    Multilevel/multifactorial lumbar spondylosis, greatest at the L3-L4 level, with a right facet joint synovial cyst that results in subarticular recess stenosis.

     
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    Old 01-10-2014, 10:21 AM   #2
    teteri66
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    Re: What to ask the neurosurgeon??

    Welcome to the board. I usually post on the "Back Problems" board but happened to notice your post. This board tends to have more members who have cervical spine issues and lumbar spineys tend to read and post on the "Back" board...That being said, let me ask you a couple questions.

    Was the ortho you saw a fellowship-trained orthopedic spine surgeon or does he also do things other than neck and back issues?

    First, the MRI is one piece of the diagnostic puzzle. It must be correlated with what is found upon physical exam, a basic neurologic exam, and after listening carefully to a description of your symptoms and how they impact your life. So it is a bit difficult to comment too much on the findings of the report...but I can give you some thoughts. I have had three lumbar surgeries, originally stemming from problems of severe stenosis and instability.

    I will be surprised if the neurosurgeon has a different recommendation for you. It is typical and customary to begin with conservative treatments when dealing with problems of the spine. Surgery is only contemplated as a last resort, when conservative measures have been tried and have failed. For your type of issues these would include a course of physical therapy to strengthen the core and back muscles, oral medications for pain and/or inflammation and perhaps a series of epidural steroid injections for the same purpose.

    These may work for awhile for you, but your type of problems come with day to day living, and are a result of that wear and tear. Due to the forces of gravity, the spine begins the aging process ahead of other parts of the body, beginning the process in our twenties.

    Discs, which are the "cushions" located between the bones of the spine, the vertebrae, tend to lose moisture as we age and gradually flatten out. This results in a loss of height and this "space" shrinks, moving the bones closer together.

    Multilevel disc space height loss greatest at the L4-L5 level asymmetric to the left, and less so at the T10-T11 level.


    When reading a MRI report, you will see more detailed "findings," and then there will be a section called "Impression" that I think of as a brief conclusions. It quickly summarizes what is going on.

    Multilevel/multifactorial lumbar spondylosis, greatest at the L3-L4 level, with a right facet joint synovial cyst that results in subarticular recess stenosis.

    Simply put, this means that at several levels, and for a number of different reasons, there are degenerative changes that are lumped together and described as spondylosis. It means you have pain and spine degeneration.
    Some doctors call it spinal arthritis. While you have degenerative changes at several levels, it is the worst at L3-L4, where there is the synovial cyst that is causing additional stenosis.

    Almost always when there is pain, it is at least in part caused by an irritation or a compression of a spinal nerve. Those flashes of pain you feel in buttocks and along the thigh is caused by the problems, particularly at L3-L4.

    If you look online for a dermatome map you will see which areas of the body are innervated by the various spinal nerves. For example if you go to the doctor and say your big toe is numb, she/he will know to check out the area of the back where the L4 nerve is located.

    I'm kind of jumping around here -- I'm a bit distracted this day as I am writing this...hope you can make sense out of it! Stenosis means narrowing. It is a condition that causes spinal nerve pain through irritation or compression of the spinal nerve. This pain can be felt right at the point of origin in the spine or anywhere along the pathway of this nerve.

    Stenosis occurs in two main places, the central canal and little openings located at each vertebral level where the spinal nerves exits the spine and goes out into the body. This opening is called the neural foramina, (foramen is the plural....). You will note that your report indicates that your central canal is somewhat smaller than "average" to begin with...you were just born that way...(me too). It just means than when we develop stenosis, it can be a bigger deal as there is even less room for the spinal nerves to exist. (Think of an old lead pipe that has filled up with mineral deposits through the years...it can become so clogged that water can barely trickle through...that's what can happen with stenosis -- the opening becomes so clogged that there is no or little room for the nerves, and eventually they become compressed to the point that they cannot function properly.

    Now, what causes stenosis? When a disc bulges, it can press into the foramina or central canal, thereby taking up space. When there is arthritic change going on, the joints of the spine that allow us to bend and twist can become enlarged. Sometimes osteophytes form and sometimes cysts form, which contribute to this enlargement. This is causing the problems at L3-L4 and to a lesser extent, the L4-L5 level.

    Sometimes these various problems occur on only one side, so the person has pain on that side. In your case, you have various issues on both sides, but it looks like you might feel more pain on the right side.

    I can go into more detail, but I hope this gives you a general idea as to what is causing your pain. Now why just conservative treatment? In the language of a MRI, radiologists use adjectives to "rank" the degree of severity of a problem like stenosis or disc bulge, etc. These words to look for begin with minimal, then mild, moderate and severe. Surgery is usually not mentioned until a problem reaches the "severe" category, or unless the person has a sudden muscle weakness such as foot drop or begins to have bladder and/or bowel involvement. Then the symptoms are considered more of a medical emergency and the person needs to consult with a doctor ASAP.

     
    Old 01-10-2014, 10:33 AM   #3
    teteri66
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    Re: What to ask the neurosurgeon??

    I see you are near Dallas. You should be able to get a well-trained, experienced spine specialist to diagnose you and to manage your conservative treatment, hopefully referring you to a spine-only physical therapist. Try to find one that specializes in orthopedic spine cases.

    I've been trying to think of questions you should ask the neurosurgeon. I imagine he will cover the basics. One thing I would ask is whether you have a spondylolisthesis. This is a situation where one vertebra slides over the top of the adjoining vertebra. It is most common at L5-S1 and L4-L5 and is best seen with a flexion/extension x-ray.

     
    Old 01-10-2014, 10:41 AM   #4
    Fr Bill
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    Re: What to ask the neurosurgeon??

    teteri66:

    Thanks for your helpful reply. I would add a bit more later today,
    Meanwhile, I'll add more later today. Thanks again.

    Last edited by Administrator; 01-10-2014 at 04:04 PM.

     
    Old 01-10-2014, 12:48 PM   #5
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    Re: What to ask the neurosurgeon??

    .

    The radiologist mentions congenital stenosis at the lowest level. It's possible that it's only at that level, but I'd guess that it's higher up, too. As Teri said, that gives you less leeway for problems.

    Exercise and PT can do a lot, and much more (imo) for the lumbar spine than for the cervical. That's because we all sit so much, and sitting is particularly hard on the lumbar spine because our leg and hip muscles get too tight.

    Last edited by Administrator; 01-10-2014 at 04:02 PM.

     
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