Herniated Disk

[TheKoman]

Hello MDers,

Pre-med here. To the point... I recently was having back and leg pains for the past 12 weeks. I found out that I have a herniated disk which is causing sciatica on my right side. Its at the L4-L5 area. Although going through a few weeks (6-8 weeks) of PT and taking naproxin and baclofen, I feel as though the situation has not improved dramatically. I still have an onset of pain in my leg and butt after sitting for 1.5 hours or walking/standing for the same about of time. The only relief is bed rest. However, Im about to start medical school and I know the illness is going to affect my ability to concentrate. Im going to see a specialist next week about surgical options. What do you think of this? Any recommendation. Oh, my MRI shows a 7mm right paramedian posterior disc protrusion causing a posterior displacement of the L5 nerve root sleeve. and the right lateral anterior thecal sac is compressed by the disc.

What are the recommended treatment options and surgical treatment options. What is the pros and cons of each treatment. Any advice would help. Please PM me thanks

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[doc05]

I think they operate on this sort of thing. I suggest you talk to your physician since he (she) is familiar with your specific case. Your doc will also be able to recommend a surgeon in your area, if that line of treatment is appropriate.

What do we think of this? (surgical treatment)

it matters not one iota. This is your decision and noone here has any idea how your disk problem affects you. Only you can answer that question. Make sure you go over the risks, benefits, and a full range of options, when you see your surgeon.

best of luck.

 

[Skylizard]

Originally posted by TheKoman
...I have a herniated disk which is causing sciatica on my right side. Its at the L4-L5 area. Although going through a few weeks (6-8 weeks) of PT and taking naproxin and baclofen, I feel as though the situation has not improved dramatically...

I would agree with the other poster in that you should really discuss personal medical problems with your physician and get consultations that you can verify the credentials.

Having said that, I was taught that in general the majority of herniated disk problems resolve or markedly improve after a six month period that includes some period of PT. That is not to say the disk is no longer herniated because it will be herniated until such time as it is physically removed. But the majority of disks do not "require" surgery. As per your question specifics, I do not know if the MRI reading you give is an indicator of requiring surgery or not. You should talk with your PCP, and a spine doctor (ortho or neuro).

 

[ortho2003]

You should probably have an EMG done before you consider surgery. The symptoms you describe and the MRI findings are consistent with nerve compression, but only with an EMG can you determine if you have nerve damage. Only then, should you consider letting someone cut into your back. Conservative treatment is always the way to start.

 

[Idiopathic]

Agreed. It was a surprise to me, but most herniations are simply left alone. The course of your condition (+20 weeks), suggests that this one may not resolve, from the literature that I have seen. I feel that surgery is in your future and you should get the consult and make the decision soon, so that recuperation can begin, if necessary. Just advice though, and certainly not a suggestion on surgery. If a qualified physician tells you that this is improving (slowly), just keep working and expect te best.

 

[Jay Shoaps]

My sympathies for the herniated disk,

I just read something in the June 4 issue of JAMA that I found very interesting, as someone who is in the recovery phase of an episode of low back pain myself. There is an article in the issue comparing xray with rapid MRI for evaluation. There is also an editorial on the subject that is interesting; I 'll quote the jist:

"Why is it so important to define the anatomy of the lumbosacral spines of patients with regional back pain? ...

... imaging the spine is the proclivity of medical practitioners and the expectation of their patients for generations. Imaging might not facilitate return to well-being, but it certainly contributes to patient satisfaction. Is this a valuable outcome? Or is this sense of satisfaction contributing to the persistence of illness? The discourse that follows imaging always relates to the demonstrable pathoanatomy. That discourse may be satisfying, but it is associated with an exacerbation of pain. That discourse, particularly as it relates to MRI, is also associated with an increased likelihood of surgery, which, for regional back pain, is no more supportable on evidentiary grounds than is imaging. Imaging is not serving as a diagnostic modality in this setting. It is one element of a complex treatment act that endows patients with unfounded notions of pathophysiology and enriches their narrative of with the private vocabulary of the treating practitioner. Patients are forever changed by these experiences, too few for the better. Whatever "satisfaction" is derived from undergoing imaging studies does not stop a third of primary care patients with back pain from using multiple providers. Imaging is not a diagnostic modality in this context; it is symbolic of the flawed logic that renders the prognosis for the return to a sense of well-being so dismal.

Community-based surveys show that virtually everyone is repeatedly challenged by self-limited regional musculoskeletal disorders that occur without extraordinary precipitants. Back pain is joined by neck, arm, and knee pain as well as headache, heartache, heartburn, and much more to form the patchwork of morbidity with which everyone must cope. Feeling well demands the sense of invincibility that we can, indeed, cope. Being well symbolizes the triumph of having the wherewithal to cope with the last episode for as long as it took for that episode to remit, cope so well that the episode is barely memorable, if at all. Being well does not symbolize avoiding challenges like regional musculoskeletal disorders; that is not possible. That is the enigma of health..."

I realize that there are people who would disargree with this but it is, at any rate, eloquent. Personally it has made me rethink somewhat the best course to take with my own occasional back difficulties, as it argues that there is good science to indicate that with low back pain the cause, mechanism and treatment are as yet fundamentally unknown.

Just my 2 cents

 

[Idiopathic]

That is a valid point. Spinal pathology may not be present in this case. Or, you could be to the point where you have compensated for the pain for so long, that you have reinforced the habits, and your body could have reinforced the pain (fantastic chapter in Foundations of Osteopathic Medicine on Spinal Pain Facilitation). I would go, images in hand, to a quality ostepath and explain the situation. Radiating leg pain is USUALLY related to trauma closer to the nerve root (i.e. herniated nucleus pulposus impinging on the L4-S3 roots) rather than peripheral muscle pain. But, sacral torsion, pelvic problems, and even leg trauma not related to the disc can cause this also. Your case does sound extreme, and I think that if an image shows a clearly herniated disc (not hard to see) then either the body cleams up the mess or someone else has to clean it up. No amount of counterstrain or muscle energy will fix an L4-L5 herniation (you can quote me on that)

P.S. if you do have surgery, research your surgeons...word of advice