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Dr. Arun Phophalia
Dr. Arun Phophalia, Doctor (MD)
Category: Health
Satisfied Customers: 29793
Experience:  MBBS, MS (General Surgery), Fellowship in Sports Medicine
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I am wondering if you could please take a look at my MRI results.

Resolved Question:

I am wondering if you could please take a look at my MRI results. Th
First here is a little history I am 36 year old female and I had back surgery in 02. After surgery I have had very few issues, until back in May when I fell off of a 4-5ft fence. I am an active person I ran a mini - marathon at the beginning of May and had no issues. However, ever since I fell off the fence I have been having pain in my low back with radiating right leg pain and numbness. I can trace a line that is numb from the back of my thigh to the top of my calf and on the outer side of my right foot . I feel that my gait is off and my ankle feels odd. I have my MRI results and I have no clue what they say. It is not as painful as 02, but the leg pain and numbness since May is starting to annoy me. I would like to get back to running and other things. The Dr cannot give me a definite cause and to me the MRI say no “significant” impingement, so why is the nerve in my leg bothering me?…do I just go back to running and suck it up and go on ..will it go away by itself or will I make it worse by running???

Here is the MRI :

Interpretation: No vertebral fractures or destructive bone marrow lesions and no spondylolysis. Straightening of the lumbar lordosis associated with lower lumbar disc degeneration. Consus medullarias terminates at T12-L1 level which is normal. There is normal midline sagittal central spinal canal dimension.

L5-S1: There is a right hemilaminectomy defect. There is marked desiccation of the disc and moderately sever narrowing of the disc space, 4 mm degenerative retrolisthesis and circumferential bulging disc and spondylotic spur complex. The central spinal canal is mildly narrowed. There is no definitive impingement of descending S1 nerve roots. Both foramina are mildly to moderately narrowed, without significant L5 ganglion impingement.

L4-L5: Moderated disc dehydration, minimal narrowing of disc space, 2 mm retrolisthesis and circumferential bulging disc annulus with posterior central annular fissure. Mild indentation of the ventral margin of the the cal sac without impingement of descending L5 nerve roots. There is no significant froaminal stenosis. Facet joint morphology is unremarkable.

L3-L4: Normal disc hydration and morphology.

L2-3: Minimal narrowing of posterior disc space. Mild decrease of central disc signal intensity. No sidnificant disc contour abnormality. There is a Schmori’s node of the inferior endplate of L2.

L1-2 & T12-L1: Normal disc hydration and morphology.

Conclusion:
1. At L5-S1, there has been right hemilaminectomy. There is marked disc degeneration with circumferential bulge and spondylotic spur. There is mild to moderate bilateral foraminal narrowing without significant impingement of L5 ganglia. There is mild central canal narrowing without significant impingement of descending S1 nerve roots.

2. At L4-5, there is disc degeneration, 2 mm retrolisthesis and circumferential bulging disc annulus, without significant central stenosis or neural impingement.

3. Subtle dehydration of L2-3 disc without significant disc contour abnormality.

Any help interpreting the results would be greatly appreciated. I tried looking up the deferent terms, but I swear it seems like the MRI report is written in a different language!
Submitted: 2 years ago.
Category: Health
Expert:  Dr. Arun Phophalia replied 2 years ago.
Hello and welcome, Lorie.

The nerve root pressure is not shown in your MRI report but the foraminal narrowing causes tissue edema and this can cause pressure on the nerves which may not be seen in MRI (the sensitivity and specificity of the MRI is 98-99%). So there is a small chance that nerve pressure can be missed. The missing problem can be detected by the nerve conduction velocity study and electromyography. So a nerve issue can be further substantiated by these electrophysiological studies. The investigations are read in context of physical examination findings and symptoms and also other investigative reports. All of them are taken together to conclude for a specific patient. A single medical imaging Like MRI alone is usually not conclusive.

A running would not be allowed till your radiculopathy symptoms are better. A comprehensive protocol of treatment would be as following;

1) Back care in the activities of daily living, which is an integral component of the treatment of back problems. Back education is one of the most important thing which teaches the basic body mechanics, like correct posture for standing, standing at a desk or drawing board, sitting, brushing teeth, washing the face, pushing and pulling a weight, lifting a weight, getting in and out of bed, sleeping, getting into and sitting in a car. The training for these routine activity helps in preventing the spasm of the muscles. One needs to consult an occupational therapist or physical therapist which can educate about the proper and improper behaviors when back is painful in case they have to sit, bend forward, lie down, walk, cough, or sneeze. Following more need to be done:

 

a) Avoid activities which increases the pain.

b) Rest intermittently

c) Avoid bending at 90 degrees

d) Pushing and pulling should be avoided till pain subsides

f) Avoid prolonged sitting and standing

g) Avoid sitting or sleeping on floor

 

2) Anti-inflammatory analgesics like ibuprofen, other analgesics and muscle relaxants

 

3) Local analgesic gels or sprays / ointment

 

4) Hot fomentation

 

5) Electrotherapy like trans cutaneous electrical nerve stimulation: done by physical therapist. Other thing are ice packs, heating pads, electrical stimulation, phonophoresis, iontophoresis, relaxation, and biofeedback.

 

6) Good supervised physiotherapy: The exercises consist of abdominal bracing, modified sit-ups, double-knee-to-chest or low back stretches, seat lifts, mountain and sag exercises, knee-to-elbow exercises, hamstring stretches, extension exercises, and extension flexibility exercises. Swimming exercises (pool exercises) are best for back pain. Initial stretching and later strengthening exercises are taught.

 

7) Lumbosacral corset or support or brace

 

8) Acupuncture

 

9) Epidural steroid shots

 

You can start the following exercises;

 

1) Straight leg raising: Lie on the bed with your back and remain in a relaxed position. Slowly raise one of your legs upward and keep it as straight as possible. Count up to ten, and slowly bring down the leg. Do the same with the other leg. Repeat this exercise ten times.

 

2) Curl ups; lie on the back with knees bent, fold arms across the chest, tilt the pelvis to flatten the back, and curl-up lifting the head and shoulders from the bed / couch. Hold for ten seconds, then slowly lower to starting position. As strength builds, aim to complete one sets of ten curls. The exercise should be done twice a day (both the sets).

 

This is a slide show for the exercises (you can pick up your own set, which suits you);

 

http://www.mayoclinic.com/health/back-pain/LB00001_D

 

You can consult following specialists (apart from your GP);

 

a) Orthopedist

b) MD in Physical medicine and rehabilitation


Please feel free for your follow up questions.

I would be happy to assist you further, if you need any more information.

 

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Customer: replied 2 years ago.

Could you explain what the MRI results say?? I tried looking them up, but I am still not certain. Last time I was at the DR office the Dr mentioned possible surgery and it freaked me out a little. I had surgery in 02 because the pain was awful, but it is not as bad this time. I have heard so many cases of failed back surgery I would not want to take my chances again. I am a police officer and I am thinking about going back with the army reserves. Do to the weight I carry at work daily and the activites that go with it I need have a good back. Do you see anything in the MRI results that would make it not a good idea to re enter the reserves? The Dr had said something about arthritis, but he never really explained what the MRI said...


thanks for your time I really appreciate it!!

Expert:  Dr. Arun Phophalia replied 2 years ago.
You are very welcome, Lorie.

With you symptoms and MRI findings and history of back surgery; avoidance of strenuous work is advised. Your MRI findings are explained below;

L5-S1: There is a right hemilaminectomy defect. There is marked desiccation of the disc and moderately sever narrowing of the disc space, 4 mm degenerative retrolisthesis and circumferential bulging disc and spondylotic spur complex. The central spinal canal is mildly narrowed. There is no definitive impingement of descending S1 nerve roots. Both foramina are mildly to moderately narrowed, without significant L5 ganglion impingement.

Right hemilaminectomy defect point to the previous surgery. Marked dessication of the disc means drying of disc, which is age related or can occur due to surgery. Narrowing of the disc space is also due to age related arthritis. Retrolisthesis is backward push of the vertebral alignment from normal. The result is mild narrowing of the central canal which can cause pressure on the spinal cord (as the cord lies in the central canal). The 5th sacral root does not have pressure and both foramen (through which nerve roots exit) have only mild to moderate narrowing thud do not cause pressure on the nerve. This is also part of the age related arthritis.

L4-L5: Moderated disc dehydration, minimal narrowing of disc space, 2 mm retrolisthesis and circumferential bulging disc annulus with posterior central annular fissure. Mild indentation of the ventral margin of the cal sac without impingement of descending L5 nerve roots. There is no significant foraminal stenosis. Facet joint morphology is unremarkable.

Between the lumbar 4 and 5 vertebra; the disc has lost some fluid, which has caused some narrowing. There is a retrolisthesis here also (which mean the vertebra has pushed slightly backward). Fissure means spacing and annulus is the ligament which gives stability to the spine. The annulus has given the spacing and through it here is a small disc bulge. There is no pinching of the nerve. Facet joints are joints between the two vertebra and they are normal. There is no narrowing (stenosis) of foramen (space) through which the nerves come out from the spine and thus there is no pressure on it.



L3-L4: Normal disc hydration and morphology.

The all structures are normal here.


L2-3: Minimal narrowing of posterior disc space. Mild decrease of central disc signal intensity. No significant disc contour abnormality. There is a Schmorl’s node of the inferior endplate of L2.

Space between the lumbar 2 and 3 vertebra has minimal narrowing. This comes with age related changes. The disc intensity changes due to loss of fluid in the disc; but there is no significant abnormality in the disc. Schmorl's nodes are arthritis of the vertebral joint.


L1-2 & T12-L1: Normal disc hydration and morphology.

This is normal.
Customer: replied 2 years ago.
One more ? and then I think I am done. I guess I am trying to figure out why my leg pain and numbness started after I fliped off a fence. Like I said I ran a mini marathon in May with no issues and couple of weeks later while chasing someone I fell off a fence about 4-5ft high and now I have all the issues. The MRI says arthritis...but since that is due to aging I doubt it hit me all at once. I am guessing I did something in the fall do you recommend chiropractic care or going to an orthopedist?? Sorry but I am not a fan of going to the Dr in general and would like to go to the right one and be done with it so I can get back to running. TheDr I have been seeing is a Physiatrist provided by work. I would like to get a second opinion and not certain who to go see.
Expert:  Dr. Arun Phophalia replied 2 years ago.
Hello Lorie,

You may try a chiropractor manipulation. The reasons are;

1) this was sudden in onset due to a fall. Thus a tissue and vertebral alignment may be beneficial.
2) your changes are not significant and there is no pinching of the nerves.

The sudden fall causing these symptoms is likely due to a change in a vertebral alignment which causes persistent tissue edema; which is not well visualized by the medical imaging (neither by MRI nor by CT).

A Piriformis syndrome can be the other possibility caused by the fall. A thorough medical history and physical examination are essential to proper diagnosis. Diagnostic testing may be used to differentiate piriformis syndrome from other causes of radiculopathy. This article reviews the pathophysiology and management of piriformis syndrome.

 

http://www.ncbi.nlm.nih.gov/pubmed/9001677

 

Following is the comprehensive treatment;

 

1) passive stretching of the piriformis muscle after application of sprayed vapocoolant.

2) physical therapy; simple muscle stretch, augmented muscle stretch, post-isometric relaxation.

3) deep electrotherapy; iontophoresis, phonophoresis, short wave diathermy, electrical stimulation, high voltage galvanic stimulation, biofeedback.

4) local analgesic patch / ointment / spray

5) anti-inflammatory analgesics; Ibuprofen (Motrin / Advil)

6) ischemic compression therapy; pressure on the points

7) massage

8) steroid shots

9) acupuncture

 

This is the resource where you can learn the piriformis stretch;


http://sportsmedicine.about.com/od/flexibilityandstretching/qt/Piriformis_str.htm



It is privilege assisting you.

Dr. Arun
Dr. Arun Phophalia, Doctor (MD)
Category: Health
Satisfied Customers: 29793
Experience: MBBS, MS (General Surgery), Fellowship in Sports Medicine
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