L4/5 rupture, Chronic LBP & DDD but nerve symptoms inconsistent with Sciatica; Refers to Knee & Front thighs – Help!

I had been under regular chiropractic care for degenerative C5/6 and neck spasm before injuring my low back nearly 14 years ago. A lumbar MRI after being hospitalized six months post injury unable to sit or walk due to "severe radiculopathy" indicated degeneration, desiccation and mild disc bulge and rupture at L4/5, degenerative changes at L3-5, a notable loss of disc height in L4/5 and the flattening of the lowermost S(?) disc (otherwise with normal signal).

When stable, my predominant LBP symptoms consist of perpetual spasm and constant stiffness from the belt-line to the (predominantly) left buttock. Tenderness in the buttock area radiates to left hip area. This pain is constant for over 10 years with ebbs and flows but never any complete relief (7-10 on pain scale). EMGs/NCV performed by my neurologist indicate moderate nerve root involvement at the injured level.

A discogram performed in 2004 also implicates L4/5, but I recall having pain also at the L3/4 level, which was tested first during the exam. I was a candidate for ADR at L4/5 by an ortho, but another ortho consult indicated that 3/4-S1 would need to be fused in order for me to see pain relief. I have been unable to zero in on the best surgical vs. non-surgical option since.

Nerve pain manifests at times as a stabbing pain in the left big toe and a burning sensation in left hip with moderate shooting pains down the left front thigh and a deep, throbbing referred pain in both knees (top near upper patella/quads). The nerve symptoms are brought on by standing, walking up hills and felt to a lesser extent while sitting. Until the past six months, however, the nerve pain came and went. Now it is nearly constant, which is why I write.

A typical day of LBP consists of extreme stiffness and inability to sit, stand or walk for long with considerable deconditioning over the years as a result of these limitations. Initially my pain was greatly reduced by walking and primarily associated with sitting. However, in the past six years it has altered pattern in that I can no longer stand and the most severe stiffness occurs upon rising in the morning. The simple act of leaning in to brush my teeth or wash my hands at the sink throws out my back with predominant spasm to the left side and buttock.

I am negative for RA, lupus and ankylosing spondylitis. The most recent MRI in 2005 indicates degenerative disc disease in lumbar spine and mild facet arthrosis; narrowing but no bone spur or stenosis.

My chiropractor has adjusted the left hip using blocks and in more recent months using a side-laying hip adjustment method with intermittent improvement to left hip/thigh pain following adjustment.

Back in 2003/2004 I completed pain management and was told by another chiropractor that I had myofascial pain syndrome and piriformis involvement (for which he was unable to achieve successful adjustment --- what type of adjustment he was attempting to do I do not recall but it was not the same side-lying method for hip adjustment as described above).

The epidural injections and/or manipulation under anesthesia resulted in swelling at the base of the spine, which I still suffer on occasion. After completing the series I had less leg pain but no improvement in the regional area of the low back. In fact, I developed new symptoms in the low back consisting of pins & needles. I also began to experience a periodic "giving out" of my back upon rising to stand that sent me crashing to the floor.

In 2005 after a period of leg weakness my left leg give out entirely while stepping down from a stair at which point I fell and injured my left knee (MCL). It took several years post pain management for the "giving out" to alleviate. I no longer experience pins & needles of any kind.

The SI joints were injected during pain management. In the months and years thereafter I began to experience SI joint movement while lying down. There as a sensation of something being somewhat dislocated bilaterally at the same location. While lying on my back or stomach with legs straight, moving both legs laterally (without lifting) sometimes triggers a painless but very loud popping sound accompanied by a shifting sensation.

In recent years the pronounced leg weakness dissipated; however, I frequently have my left ankle seize and "give out" while walking at a moderate pace, typically within the first two minutes after I rise from a long period sitting in a chair (my left ankle has been subject to repeated sprain but the giving out of the joint occurred many years post injury so I tend to suspect it is related to nerve dysfunction from my low back). With respect to the referred pain described above, most of the time I do not suffer symptoms below the knee. Intermittently I experience numbness/cramping in the top of the foot in the toe second to the big toe (left foot predominant).

PROBLEM

What brings me cause for concern, however, is that in the past six months shooting front thigh pain, tenderness and burning in the left hip near iliac crest, and very strong throbbing referred pain in the TOP of my knee joints above the patella and into the quads (in this case the right knee predominantly). This pain is occurring more and more regularly and I need a means to stop it (stretch, what have you). Meanwhile, tenderness and spasm is now involving the right buttock and not just the left. The flare in nerve symptoms (vs. the usual spasm and stiffness in the low back) occurred in November around Thanksgiving and has continued to resurface at faster intervals since.

QUESTION

Firstly, I would like to know what type of treatment my chiropractor might offer other than hip adjustments. He really hasn't manipulated my spine below the neck and mid back, and all but the hip adjustments occur while lying face-down on the table. Is this hands-off approach to the lumbar spine normal when it comes to chiropractic care or are there other approaches/techniques I might benefit from were I aware of the options?

Secondly, in researching the issue it would appear that I am not suffering the classical symptoms of sciatica because I do NOT have pain down the back of the thigh or in the calf or shin areas. Is the referred pain pattern I have described more consistent with L3/4 than L4/5 --- or something else entirely?

After over a decade of suffering I feel I need better solutions. I have been treating with my chiropractor over 20 years but I find myself wondering if there aren't better options either for my chiropractor or to look into surgically.

In conclusion, this 24/7 pain has robbed me of a normal and productive life. To further isolate what the primary pain generator may be and what best to focus rehabilitative efforts on, I would greatly appreciate some pointers as to what might have been missed in terms of an in-office physical exam and treatment based on the above.

Thank you for your time. I look forward to a reply and possible referral.

Hello,
Thank you for a very full report.

I'd like to ask you do a few things:

* Take off your shirt, ask your wife to stand behind you and place her fingers on the iliac crests on either side. To her (inexperienced) eye, is there an obviously high/low side or are your hips more or less level? You can get confirmation from XR if they were taken standing. Are your hips, sacral base parallel to mother Earth?

* Bend slowly forwards, carefully, then backwards, then sideways and slightly backwards. Let me know what happens, focussing firstly on your back, and then any difference in the legs. Is one leg tighter for example. Does bending to the side shoot down the leg, and where?

* Do the Slump Test (use the Search this site function at C-H) and let me know the result.

* Then do these little tests for muscle strength: http://youtu.be/gV-cdz8B18E

* Testing for the sciatic nerve is fairly simple, as in the Slump test, but the Femoral nerve test is far more difficult. Ask your chiro to do it for you, and let me know the result.


Are you doing any exercises EVERY morning before getting out of bed, and several times a day? They take less than two mins. See Lower back exercises at C-H.

It would seem that you have had fairly classic L4-L5 problems over the years, it radiates to the great toe. That's the sciatic nerve. But now it seems that the Femoral nerve is involved, higher in your lumbar spine as you suspect, hence the pain in the front of the leg.

Let me know. Perhaps print this out, and take to your chiro. Be diplomatic!

Dr B




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Interesting challenges of the day

1. Mr S is a 76 year old man with neck pain of some 9 months duration. Luckily, most of the discomfort is upper cervical which is only rarely arthritic; his lower cervical spine is a degenerative mess that I've left alone. After seven treatments his pain and stiffness is 50 percent better, and he's happy in the circumstances. He can sleep through the night now and that makes a huge difference.

2. Mr P is 32 year old man with very severe lower back pain radiating to the big toe which is 30 percent numb. He had an episode three weeks ago, took anti inflammatories and was soon better as is typical of the medial disc herniation. But before it healed, after a trivia it came roaring back, much worse. The characteristic crossed sign was evident; sitting in a chair, straightening the right leg provoked severe left back pain and tingling in the leg. He's doing well.

3. Severe lower back pain is scary; just ask Mrs P. Just watching her get out of the car I she was in trouble; she had a slipped disc at L4 making her lean towards the opposite side; luckily she had no pain in the leg. Despite family pressure that this was far too severe for a chiropractor, she persevered. Within five days she was standing upright, and after two weeks almost painfree. 

Despite a hectic job, she wisely took my advice and stayed home for what I call exercising bed rest.

4. Mr S has had lower back, groin and back of thigh and calf pain for fourth months.

He has a pincer deformity in the hip causing the stabs in the groin, and a degenerative facet causing the sciatica. Both are responding well to chiropractic and he's well pleased; sixty five percent better after three treatments.

5. Mr T is a wise man; he's taken a warning TIA seriously and has lost 15 pounds, and has at least as much again to lose. A change to a low starch diet and half hour daily walk has made the difference; but the walking is making his foot and back miserable. The expensive orthotic is hopeless; luckily his hips and back are fine, but he needs a simple heel lift.

6. I too have had serious lower back issues, luckily fixed by my own chiropractor; so I too have to do my exercises, take care when lifting supers full of honey, gardening and using the chainsaw. Regaining the function of your spine is just as important as the pain.

7. My own granddaughter, only 7 is hypermobile giving her pelvic, knee and ankle issues. Xrays show a mildly dysplastic hip. Years ago we would have called it growing pains. She too regularly needs chiropractic care and luckily responds well. Increased range of motion is more difficult than too stiff in my opinion. Our care is for kids too.

8. This 65 year old lady is a serious gardener; every day she is bending, lifting and digging for 2 to 3 hours a day. It regularly catches her in the sacroiliac joint, so she has a treatment once a month that sorts it out. She does her lower back exercises faithfully.

9. This 88 year old lady is an inspiration; every day she is busy in the community. With a nasty scoliosis she manages very well with a chiropractic adjustment every six weeks and exercises faithfully done.  

10. Mr X is a 71 year old retired man who wants to continue with maintenance care every six to eight weeks; he had suffered from two years of lower back pain when he first came a year ago. He has no discomfort now after 8 chiropractic treatments, but is aware that danger lurks.

11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.

12. Mr D is a 38 old year man with chronic shoulder pain after a rotator cuff tear playing cricket. It responded well to treatment, but he knows he must do his exercises every day; for two years he couldn't sleep on that shoulder.

13. Mr D, a 71 year old man, has a severe ache in the shoulder and midback since working above his head. Trapped nerve tests are negative but he has advanced degenerative joints of Luschka; after just two treatments he is 50 percent better. Can we reach 90?

And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.



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