Q:

I injured myself while at work almost three years ago. This was a sudden trip and stumble action. I have had constant pain ever since. This pain is worse in the morning but smooths out during the day providing I don’t do any heavy lifting bending or highly fiscal activities. Sitting for prolonged periods is also a problem. It just seems that there is no happy medium to control this.I have had a MRI which a shall attach.

I have seen surgeons who do not recommend surgery at this time and have had several (nerve blocks) injections with the intent to find which nerve was the problem and then to remove it. This never panned out. This was proposed even though my spinal canal is well maintained.

I have also gone through all the usual regimes of exercise, chiropractic,stretching and return to work programs, all of which saw little to no results. I’ve also tried several conventional drugs and even antidepressants also without success.

Typical symptoms are:constant lower back pain.
left hip and leg pain
periodic numbness in both legs and often arms
frequent inability to straighten posture after bending or sitting
worse in morning and after activity
crushing lower back pain while standing in static position
frequent jolts and twinges in left hip and leg

I’m a mail man and typically walk ten plus miles a day just while delivering. I’ve made several attempts to return to work only to fail. As one could predict my insurance company says that there is not enough medical info to suggest that I cannot do my job.

What do you think? Based on the MRI and symptoms are there any other options open to me or should I look for another job. My family doctor thinks I should look for a less demanding career.

I often wonder if perhaps the leg and hip pain is not causing the back pain and should I insist on a MRI in this area.

A

Thanks for your interesting question. One thing seems clear: Based on the MRI report, you have degenerative disc disease and foraminal stenosis, along with Modic type II changes at the L5-S1 level. In English, this means that you clearly have a chronic degenerative disc disease. The key word here is chronic - I agree that spinal fusion surgery would not necessarily be beneficial at this point. There is nothing in the MRI report that suggests an active process (nerve root compression) causing the left hip-leg pain that could be fixed by surgery. If instability can be shown, you may benefit from an spinal fusion procedure (a large operation where the two lowest vertebrae are fused by bone transplant / metal instrumentation), but this is not guaranteed. If you had sudden, sharp, stabbing back pain, these might be caused by L5-S1 instability, and that could be remedied by interbody fusion. However, you do not complain of such symptoms, and the MRI is suggestive of a more chronic process, and not of acute instability. A flexion-extension X-ray and MRI could shed some light on this. 

It’s a difficult situation, and it seems you’ve been properly examined. You would benefit from daily NSAID (anti-inflammatory) medication. Abdominal and back muscle training is vital, and exercise such as Pilates might be beneficial to you. I agree with your family doctor that you may want to look into some other employment opportunities that would not require you to walk such long distances. I’m rather surprised the insurance company does not consider the existing medical evidence sufficient.

If all else fails, and the situation does not get better at all, get a second opinion from an expert back surgeon and talk about decompressive and interbody fusion surgery. Bring the MRI pictures with you to the appointment.

Q:

Hello doctor, 
i am a 54 yo male . I started having lower back problems in 2003. Since then i have received pain management, 3 steroidal injections, a facet block, a radio frequency block, multiple MRI, oa 2/28/05 i underwent a laminectomy, and after 8 weeks returned to work,for 2 1/2 months only to feel worse than ever. Returned to neurosurgeon who sent me for a diskography, from which the performing Dr. said it looked like i did not need a fusion..Waiting on CT scan results. Am i at the end of the line, i can’t go on like this. Its been a long painful time. Where do i go now?

A:

i’m sorry to hear about your continuing back problems. It would help to know what sort of symptoms you are experiencing, back pain or radiating pain to lower limbs?

In any case, it sounds like your doctors are evaluating you thoroughly, and not rushing to do a fusion, which is wise. Generally, intervertebral fusion should only be carried out if the symptoms and findings clearly indicate a problem with spinal instability. Because of the limited information available i cannot say anything about your situation in particular, but generally speaking, chronic back pain patients, especially when there is an accompanying chronic pain syndrome, rarely if ever benefit from spinal fusion. On the contrary, the situation may get much worse. There are some very carefully selected patients that may benefit.

If there is chronic pain, a consultation with a pain specialist should be done. Ideally, a team of physicians including an experienced spinal surgeon, pain specialist and physiatrist, should evaluate your case.

Q:

I am looking for some information on this process - Dynesys. It is an alternative to a standard fusion, in that it provides some flexibility, rather than a fixed post. Has anyone had the procedure?

A:

Thanks for your question. Unfortunately, I don’t have any personal experience in using the “Dynesys” spinal fusion system. However, judging by a presentation here: Dynesys Website

it does look a lot like a standard spinal stabilization instrumentation system, although it may or may not have additional benefits. In any case, my guess is that the big decision is whether you need spinal fusion in the first place or not. Once you know that, the rest -including choosing the stabilization system - should be easier.