Seeking advice on treatment options for spinal degeneration
April 30, 2017 1:46 PM Subscribe
My wife has been diagnosed with degeneration in the lumbar region of her spine. We’re seeking advice on treatment options to explore before resorting to surgery.
My wife is 52 years old. Aside from the problems with her spine (as described below), she is healthy and fit, and she has been athletic & physically active for most of her life. She is not overweight. She does not smoke. She has no history of physical trauma. About a year ago, she started noticing transient numbness in her right foot. Soon afterwards, she started experiencing periodic weakness and pain in her right leg, along with pain in her lower back. Standing or walking makes the symptoms worse. An MRI revealed degeneration in the L4 and L5 region of her spine.
The MRI report is scary to read. The main problem seems to be stenosis, but there is also scoliosis, listhesis, desiccation of the intervertebral disks, bulging of the disks, osteophytes, and facet arthropathy. (I’ve copied the full text of the report at the end of this post). My wife has never had any serious health problems, so the diagnosis came as quite an unpleasant surprise.
The pain, numbness, and weakness have caused her to stop playing volleyball and softball, much to her distress. She also can’t take walks in the park anymore, which is something we used to enjoy doing together. Overall, the symptoms have a definite negative effect on her quality of life, but she is not overtly disabled – she can still walk moderate distances, drive, and perform the usual activities of daily life.
My wife is under the care of a spinal specialist (surgeon). To his credit, he didn’t push surgery right away and instead started with conservative treatment options. Physical therapy had no effect. Neurontin (gabapentin) had no effect on the pain or numbness, and also caused unpleasant side effects. Two epidural injections of steroid/lidocaine had no effect, or might have even made the pain worse. Thrice-daily oral ibuprofen has minimal effect, though she continues to take it. At my wife’s last appointment, the specialist said that surgery is the only available option left, but he admitted that there is a chance that the surgery will not work, or might even make her condition worse. He told her to go home, do some reading, think about it, and then contact his office if she decides to move forward with the surgery.
My wife is thinking about trying acupuncture next, though she hasn’t scheduled an appointment yet. I’ve also read about chiropractic treatments (such as distraction manipulation). My wife and I are both largely skeptical about alternative medicine, but we want to exhaust all reasonable options before considering surgery.
Does anybody have any other thoughts or suggestions?
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- EXAM: MRI LUMBAR SPINE WITHOUT CONTRAST
- HISTORY: Increasing low back pain with right leg and foot numbness since 7 months. No prior lumbar spine surgery.
- TECHNIQUE: Multiplanar, multisequence MRI of the lumbar spine was performed without contrast administration. This study was performed on a high-field 1.5T MRI scanner.
- COMPARISON: No prior lumbar spine imaging available for comparison.
- FINDINGS: For the purpose of this dictation, it is assumed that there are 5 non-rib-bearing, lumbar-type vertebrae with the lowermost fully-segmented vertebra labelled as L5.
- There is dextroscoliotic curvature of the lower lumbar spine with right lateral listhesis of L4 on L5 and left lateral listhesis of L2 on L3. Trace retrolisthesis of L2 on L3 and L3 on L4 is also noted. Lumbar vertebral body height is maintained at all levels. There are edematous endplate marrow changes from L2-L3 through L4-L5 (Modic type I). No focal aggressive osseous lesion is identified. There is intervertebral disc desiccation throughout the lumbar spine with height loss from L2-L3 through L4-L5, worst at L2-L3 with endplate irregularity. Prominent anterior L2-L3 osteophyte is also noted.
- Conus medullaris terminates at mid L1 level. Included distalmost cord and conus medullaris are normal in signal intensity.
- Included paraspinal soft tissues are grossly unremarkable. Included portions of the sacroiliac joints are unremarkable.
- Individual levels:
- T12-L1: No significant degenerative disc disease, spinal canal stenosis or neural foraminal narrowing. No severe facet arthropathy.
- L1-L2: Minimal diffuse disc bulge without significant spinal canal stenosis or neural foraminal narrowing. Mild bilateral facet arthropathy.
- L2-L3: Diffuse disc bulge causing mild spinal canal stenosis. Right foraminal disc osteophyte causing moderate neural foraminal narrowing with osteophyte contacting and possibly impinging the exiting right L2 nerve root. Moderate bilateral facet arthropathy.
- L3-L4: Diffuse disc bulge causing mild to moderate spinal canal stenosis. Left foraminal facet and disc osteophytes causing severe neural foraminal narrowing with impingement of the exiting left L3 nerve root. Severe bilateral facet arthropathy with right facet joint fluid.
- L4-L5: Diffuse disc bulge causing moderate spinal canal stenosis with crowding of the cauda equina nerve roots. Bilateral foraminal facet and disc osteophytes with severe neural foraminal on right causing impingement of the exiting right L4 nerve root. Disc osteophyte also contacts the exiting left L4 nerve root with questionable impingement. Severe bilateral facet arthropathy.
- L5-S1: Diffuse disc bulge with small central protrusion causing mild spinal canal stenosis. Bilateral foraminal facet and disc osteophytes causing moderate left and severe right neural foraminal narrowing with impingement of the exiting right L5 nerve root. Severe bilateral facet arthropathy.
- Incidental note is made of intracanal S2 perineural (Tarlov) cyst.
- IMPRESSION:
- 1. Dextroscoliotic lumbar spine curvature with spondylolisthesis as above.
- 2. Multilevel degenerative disc disease with resultant spinal canal stenosis, worst at L4-L5 with crowding of the cauda equina nerve roots.
- 3. Multilevel foraminal facet and disc osteophytes with impingement of the exiting nerve roots as detailed above. Findings are worst at L4-L5 with impingement of the exiting right L4 nerve root. Recommend correlation with patient's symptomatology.
- 4. Multilevel bilateral facet arthropathy.
Result: L2 foraminal stenosis , L4 stenosis. not Corda Equine syndrome
My wife is 52 years old. Aside from the problems with her spine (as described below), she is healthy and fit, and she has been athletic & physically active for most of her life. She is not overweight. She does not smoke. She has no history of physical trauma. About a year ago, she started noticing transient numbness in her right foot. Soon afterwards, she started experiencing periodic weakness and pain in her right leg, along with pain in her lower back. Standing or walking makes the symptoms worse. An MRI revealed degeneration in the L4 and L5 region of her spine.
The MRI report is scary to read. The main problem seems to be stenosis, but there is also scoliosis, listhesis, desiccation of the intervertebral disks, bulging of the disks, osteophytes, and facet arthropathy. (I’ve copied the full text of the report at the end of this post). My wife has never had any serious health problems, so the diagnosis came as quite an unpleasant surprise.
The pain, numbness, and weakness have caused her to stop playing volleyball and softball, much to her distress. She also can’t take walks in the park anymore, which is something we used to enjoy doing together. Overall, the symptoms have a definite negative effect on her quality of life, but she is not overtly disabled – she can still walk moderate distances, drive, and perform the usual activities of daily life.
My wife is under the care of a spinal specialist (surgeon). To his credit, he didn’t push surgery right away and instead started with conservative treatment options. Physical therapy had no effect. Neurontin (gabapentin) had no effect on the pain or numbness, and also caused unpleasant side effects. Two epidural injections of steroid/lidocaine had no effect, or might have even made the pain worse. Thrice-daily oral ibuprofen has minimal effect, though she continues to take it. At my wife’s last appointment, the specialist said that surgery is the only available option left, but he admitted that there is a chance that the surgery will not work, or might even make her condition worse. He told her to go home, do some reading, think about it, and then contact his office if she decides to move forward with the surgery.
My wife is thinking about trying acupuncture next, though she hasn’t scheduled an appointment yet. I’ve also read about chiropractic treatments (such as distraction manipulation). My wife and I are both largely skeptical about alternative medicine, but we want to exhaust all reasonable options before considering surgery.
Does anybody have any other thoughts or suggestions?
=================
- EXAM: MRI LUMBAR SPINE WITHOUT CONTRAST
- HISTORY: Increasing low back pain with right leg and foot numbness since 7 months. No prior lumbar spine surgery.
- TECHNIQUE: Multiplanar, multisequence MRI of the lumbar spine was performed without contrast administration. This study was performed on a high-field 1.5T MRI scanner.
- COMPARISON: No prior lumbar spine imaging available for comparison.
- FINDINGS: For the purpose of this dictation, it is assumed that there are 5 non-rib-bearing, lumbar-type vertebrae with the lowermost fully-segmented vertebra labelled as L5.
- There is dextroscoliotic curvature of the lower lumbar spine with right lateral listhesis of L4 on L5 and left lateral listhesis of L2 on L3. Trace retrolisthesis of L2 on L3 and L3 on L4 is also noted. Lumbar vertebral body height is maintained at all levels. There are edematous endplate marrow changes from L2-L3 through L4-L5 (Modic type I). No focal aggressive osseous lesion is identified. There is intervertebral disc desiccation throughout the lumbar spine with height loss from L2-L3 through L4-L5, worst at L2-L3 with endplate irregularity. Prominent anterior L2-L3 osteophyte is also noted.
- Conus medullaris terminates at mid L1 level. Included distalmost cord and conus medullaris are normal in signal intensity.
- Included paraspinal soft tissues are grossly unremarkable. Included portions of the sacroiliac joints are unremarkable.
- Individual levels:
- T12-L1: No significant degenerative disc disease, spinal canal stenosis or neural foraminal narrowing. No severe facet arthropathy.
- L1-L2: Minimal diffuse disc bulge without significant spinal canal stenosis or neural foraminal narrowing. Mild bilateral facet arthropathy.
- L2-L3: Diffuse disc bulge causing mild spinal canal stenosis. Right foraminal disc osteophyte causing moderate neural foraminal narrowing with osteophyte contacting and possibly impinging the exiting right L2 nerve root. Moderate bilateral facet arthropathy.
- L3-L4: Diffuse disc bulge causing mild to moderate spinal canal stenosis. Left foraminal facet and disc osteophytes causing severe neural foraminal narrowing with impingement of the exiting left L3 nerve root. Severe bilateral facet arthropathy with right facet joint fluid.
- L4-L5: Diffuse disc bulge causing moderate spinal canal stenosis with crowding of the cauda equina nerve roots. Bilateral foraminal facet and disc osteophytes with severe neural foraminal on right causing impingement of the exiting right L4 nerve root. Disc osteophyte also contacts the exiting left L4 nerve root with questionable impingement. Severe bilateral facet arthropathy.
- L5-S1: Diffuse disc bulge with small central protrusion causing mild spinal canal stenosis. Bilateral foraminal facet and disc osteophytes causing moderate left and severe right neural foraminal narrowing with impingement of the exiting right L5 nerve root. Severe bilateral facet arthropathy.
- Incidental note is made of intracanal S2 perineural (Tarlov) cyst.
- IMPRESSION:
- 1. Dextroscoliotic lumbar spine curvature with spondylolisthesis as above.
- 2. Multilevel degenerative disc disease with resultant spinal canal stenosis, worst at L4-L5 with crowding of the cauda equina nerve roots.
- 3. Multilevel foraminal facet and disc osteophytes with impingement of the exiting nerve roots as detailed above. Findings are worst at L4-L5 with impingement of the exiting right L4 nerve root. Recommend correlation with patient's symptomatology.
- 4. Multilevel bilateral facet arthropathy.
Result: L2 foraminal stenosis , L4 stenosis. not Corda Equine syndrome
Best answer: I would try a different physical therapy group and see if that helps.
Read about piriformis syndrome and see if some of those exercises help.
Surgery sound reasonable after this length of time.
posted by SyraCarol at 2:06 PM on April 30, 2017
Read about piriformis syndrome and see if some of those exercises help.
Surgery sound reasonable after this length of time.
posted by SyraCarol at 2:06 PM on April 30, 2017
Best answer: I have this, almost down to a symptom. You say she didn't do well with Gabapentin (Neurontin.) Has she tried Cymbalta? I found Cymbalta a lot more effective for the nerve pain than the Gabapentin. Lyrica is another option, though I haven't tried it myself.
If she's on Advil right now, perhaps she can try Meloxicam, Diclofenac or Celebrex instead? I've worked my way up from Meloxicam to Celebrex. The one bad thing about these drugs is that they can be very, very hard on the stomach.
She might also consider a TENS unit. While the spinal cord damage can't be relieved by it, relaxing the muscles around the spine is also pretty helpful for me. When my muscles are tense, it exacerbates my symptoms. You can get these on Amazon now, super cheap. I'm so glad I got mine.
In the same range of trying to take care of the muscles to relieve tension on the spine, I find topical Lidocaine stickers to be very useful, too. They can be kind of pricey depending on your insurance. But they can be trimmed to specific sizes and areas, so you can make them last.
Acupuncture might help (might not, probably can't hurt.) But my doctors have warned me to avoid chiropractors and massage therapists who are not physical therapists. The degenerative bone can pancake and splinter, and cause more damage to the spine.
Best of luck to you and your wife. This is pretty tough condition to deal with, especially when you started out athletic and active.
posted by headspace at 5:35 PM on April 30, 2017 [2 favorites]
If she's on Advil right now, perhaps she can try Meloxicam, Diclofenac or Celebrex instead? I've worked my way up from Meloxicam to Celebrex. The one bad thing about these drugs is that they can be very, very hard on the stomach.
She might also consider a TENS unit. While the spinal cord damage can't be relieved by it, relaxing the muscles around the spine is also pretty helpful for me. When my muscles are tense, it exacerbates my symptoms. You can get these on Amazon now, super cheap. I'm so glad I got mine.
In the same range of trying to take care of the muscles to relieve tension on the spine, I find topical Lidocaine stickers to be very useful, too. They can be kind of pricey depending on your insurance. But they can be trimmed to specific sizes and areas, so you can make them last.
Acupuncture might help (might not, probably can't hurt.) But my doctors have warned me to avoid chiropractors and massage therapists who are not physical therapists. The degenerative bone can pancake and splinter, and cause more damage to the spine.
Best of luck to you and your wife. This is pretty tough condition to deal with, especially when you started out athletic and active.
posted by headspace at 5:35 PM on April 30, 2017 [2 favorites]
This sounds extremely similar to my mother's back problems she's been having for over a decade, including the numbness, pain, scoliosis, the problematic vertebrae in question, etc. My mom was scared off by the prospect of surgery so she elected to lose some weight, fix a bad knee that was exacerbating the issues, and go through some physical therapy. She's now in her mid 60s and can't get through the day without a lot of very strong pain medication (including the Lidocaine stickers mentioned above), and she is fairly limited in physical activity. She's lost 2.5 inches of height. She'll never get the surgery at this point. Scoliosis is not something a chiropractor can fix. If your wife values being physically active, I would recommend the surgery, because risks of the surgery notwithstanding, my anecdotal experience is that it's almost impossible to get back to the previous lifestyle with the alternatives. Obviously I am not a doctor and you should get a second opinion on the technical front, but from a family member perspective, I really think my mother missed her window for the surgery and I am disappointed for her.
posted by olinerd at 5:40 PM on April 30, 2017
posted by olinerd at 5:40 PM on April 30, 2017
Best answer: I have or had very similar symptoms and diagnosis. I did most of what your wife has done to date. I eventually had surgery. I actually have a fusion at L4-L5 and in my cervical spine too (two levels). For me, the surgery worked. I was able to rejoin my ice hockey team at the age of 40+, and now in my 50s can do most anything I want. I would do the surgeries again in a heartbeat. However, I acknowledge that they are not for everyone. For every success story, I am sure you can find one that was not so successful. What exactly would the surgeon do if she were to operate?
Before I did surgery, I would work with a PT to strengthen my core. I would consider doing yoga to improve strength and flexibility. That all helped my pain tremendously until it didn't. It did buy me lots of time. A year or two before I opted for surgery. To me, the decision to have surgery came only after I could say to myself if surgery was not successful that I had exhausted my other options so that if it did not work, I would have no regrets for trying. Also, ask the doctor if the nerve damage or nerve impingement is permanent. At the point when my doctors said that if I let it go much longer I might not regain the strength and the felling in my leg or arm, it made the decision easier.
The other thing to know is that the recovery time can be considerable and the rehab, if done right, can be difficult. Rehab is a big commitment in terms of time and effort. The odds of surgery being successful are greatly increased by the patient's willingness to rehab. Or put another way, the odds of success go down greatly if you do not do your rehab. I know for me, my last surgery was when I was around 50. I heal slower than I did as a younger man, I notice pain more, my time is harder to come by, etc.
Having said all of that, my back and neck are doing great!! I play softball weekly, I bike, I walk, I play basketball and I do yoga. I cannot tell you how much the surgery improved my life.
posted by AugustWest at 8:56 PM on April 30, 2017 [1 favorite]
Before I did surgery, I would work with a PT to strengthen my core. I would consider doing yoga to improve strength and flexibility. That all helped my pain tremendously until it didn't. It did buy me lots of time. A year or two before I opted for surgery. To me, the decision to have surgery came only after I could say to myself if surgery was not successful that I had exhausted my other options so that if it did not work, I would have no regrets for trying. Also, ask the doctor if the nerve damage or nerve impingement is permanent. At the point when my doctors said that if I let it go much longer I might not regain the strength and the felling in my leg or arm, it made the decision easier.
The other thing to know is that the recovery time can be considerable and the rehab, if done right, can be difficult. Rehab is a big commitment in terms of time and effort. The odds of surgery being successful are greatly increased by the patient's willingness to rehab. Or put another way, the odds of success go down greatly if you do not do your rehab. I know for me, my last surgery was when I was around 50. I heal slower than I did as a younger man, I notice pain more, my time is harder to come by, etc.
Having said all of that, my back and neck are doing great!! I play softball weekly, I bike, I walk, I play basketball and I do yoga. I cannot tell you how much the surgery improved my life.
posted by AugustWest at 8:56 PM on April 30, 2017 [1 favorite]
I have pain issues elsewhere, have been through everything on your list (also to no useful effect). I take a relatively low dose of extended-release morphine, and another opiate on an as-needed basis. The extended release means I can sleep and so on; the as-needed means I can occasionally do something (like walk through a park). I'm kind of surprised by the ibuprofen-->surgery with no better options for pain relievers offered, even if it only buys her a few years before surgery.
I know there are a lot of scare stories in the news about addiction right now, but the number of people with legit pain who take the drugs as prescribed and then end up junkies is so tiny as to be meaningless. People claiming they ended up smack addicts because their dentist gave them a two-week Rx for a mild opiate are, like most addicts, usually liars. I do not mean to be unsympathetic to addicts; that is a horrible state of existence. But there is a lot of evidence to show that pain patients and people at risk of addiction without much if any actual pain react differently to opioids.
There isn't good evidence to support acupuncture or myofascial release, and chiropractic is of course riddled with quackery. I totally understand the temptation to 'pursue all avenues,' but, try to remember that pain and fear do not make alternative medicine into medicine. It will be time-wasting, money-wasting, disappointing, and frustrating. Unless her physician says "yes, there is good evidence for X when it comes to her specific problems," just skip the woo. Good luck.
posted by kmennie at 11:20 AM on May 1, 2017
I know there are a lot of scare stories in the news about addiction right now, but the number of people with legit pain who take the drugs as prescribed and then end up junkies is so tiny as to be meaningless. People claiming they ended up smack addicts because their dentist gave them a two-week Rx for a mild opiate are, like most addicts, usually liars. I do not mean to be unsympathetic to addicts; that is a horrible state of existence. But there is a lot of evidence to show that pain patients and people at risk of addiction without much if any actual pain react differently to opioids.
There isn't good evidence to support acupuncture or myofascial release, and chiropractic is of course riddled with quackery. I totally understand the temptation to 'pursue all avenues,' but, try to remember that pain and fear do not make alternative medicine into medicine. It will be time-wasting, money-wasting, disappointing, and frustrating. Unless her physician says "yes, there is good evidence for X when it comes to her specific problems," just skip the woo. Good luck.
posted by kmennie at 11:20 AM on May 1, 2017
Response by poster: @kmennie: The pain is only part of the problem. The other problems are weakness and numbness in her right leg. I don't think the opiates would affect those other symptoms.
posted by alex1965 at 12:04 PM on May 1, 2017
posted by alex1965 at 12:04 PM on May 1, 2017
I used to be active and am now sidelined by back and hip issues. I do not have symptoms and causes nearly as severe as your wife's. However, I also have some spondylolisthesis (mine at L5-S1), which is dislocation due to a fracture. There is no chiropractic or acupuncture technique that will help a fracture. Acupuncture may help pain, but, as you say, not numbness and weakness. Chiropractic is largely unregulated and infiltrated by quacks, caveat emptor.
If I were your wife, I would also find all the online communities with people posting about their similar conditions and surgical outcomes. And I'd get on Medline and look at outcomes there.
And then, if I trusted the surgeon, I'd have the surgery. Not only is it painful, it's also dangerous to walk around on numb and weak legs and feet.
posted by ImproviseOrDie at 1:33 PM on May 1, 2017
If I were your wife, I would also find all the online communities with people posting about their similar conditions and surgical outcomes. And I'd get on Medline and look at outcomes there.
And then, if I trusted the surgeon, I'd have the surgery. Not only is it painful, it's also dangerous to walk around on numb and weak legs and feet.
posted by ImproviseOrDie at 1:33 PM on May 1, 2017
This thread is closed to new comments.
He runs two intensive treatment centers (one in PA and one in AZ) in addition to a lot of private practitioners who are located all over. I recently came back from a training seminar they held and we discussed some case studies of patients with stenosis, degenerating discs, etc. that had positive outcomes and managed to avoid surgery and improve their ability to function after MFR treatment.
Definitely get more than one surgeon's opinion before you ultimately decide what to do. It's good that your wife was healthy and active before she realized this was going on - that means her body is better prepared to undergo and recover from a surgery, if necessary.
posted by zdravo at 1:59 PM on April 30, 2017