Left lumbosciatic pain from double disc protrusion
35-year-old female experienced an episode of lower back pain. Her doctor prescribed injections with Orudis, followed by further treatment with Voltaren. The treatment resulted in a simple remission of pain, that then re-appear at the same intensity as initially. The doctor established a new treatment that consisted of Indoxen and Bentelan. The patient experienced a remission of symptoms until even more intense lumbar pain returned spreading to the left leg. She recieved Voltaren, Muscoril, and Indoxen. Lumbar-sacral NMR showed disc central protrusion. Left lumbosciatic pain from L4-L5 and L5-S1 annular protrusion was diagnosed. She was treated by Tricortin, Toradol, and Paracetamol together with orthopaedic brace and medical posture gymnastics with caution. Epidural treatment and ozone treatment were recommended if pain persists. Surgery was not recommended in view of her young age. Despite the drug treatments, the patient still complains of strong pain in the lumbar region involving the entire left leg.
1) Would you recommend surgery? What is the success rate for this type of surgery? What Italian centre do you recommend for this case?
2) Is there a permanent medical cure?
Female, 35 years old, Italy
Diagnosis: Left lumbosciatic pain from double disc protrusion
In June 2009 manifestation of lower back pain while carrying home shopping bags. Thinking it was simply a pulled muscle the patient of her own accord applied “Dicloreum plasters” in the painful area for 3 days continuously. Despite this treatment the pain spread to the left lower limb forcing the patient to consult her family doctor. The family doctor diagnosed a “left lumbosciatic pain” and prescribed injections with vials of Orudis at a dose of 2 intramuscular injections per day for 6 days which brought little relief, followed by further treatment with vials of Voltaren - 2 intramuscular injections per day for a further 6 days. The treatment resulted in a simple remission of pain for about 8 hours following the administration of the anti-inflammatory medication, to then re-appear at the same intensity as initially.
On 06/2009 a CAT scan was carried out on the lumbar-sacral spine without contrast medium which showed: “Bone diameters in the spinal canal within normal limits. Spondylosis of the endplates concerned. Reasonable hypertrophy of the interapophyseal joints. Disc L3-L4 is contained. Moderate central and slightly bilateral protrusion of disc L4-L5 with marginal resting on endospinal structures. Central intraspinal and marginally bilateral protrusion of disc L5-S1 with reasonable compressive imprint in front of the dural sac and on the top of S1 roots, of minimum importance on the ventral emergence of both L5 roots.” The family doctor, following the aforementioned results, established a new basic treatment as follows: Indoxen 25 mg at a dose of 1 tab x 3 per day after meals and Bentelan 1.5 mg at a dose of 1 tab x 2 per day. At the same time the patient received acupuncture treatment which was partially beneficial (after a sitting she felt no pain for 3-4 days).
At the end of the aforementioned treatment the patient experienced a total remission of symptoms until August 2009 when, while she was lying on the sofa, the lumbar pain returned spreading to the left leg, and the level was more intense than the previous episode. This resurgence of the symptoms forced the patient to visit the Emergency Room where a further drug therapy was prescribed: voltaren vial + Muscoril vial 1+1 I.M. for 5-6 days. As there was no relief from the symptoms, the family doctor continued treatment with Indoxen 25 mg at a dose of 1 tab x 3 per day after meals for a total of three boxes.
As the pain continued, on 09/2009 the patient underwent a Lumbar-sacral NMR scan examination which showed: “Bone canal diameters within normal limits. At L4-L5 there is a slight circumferential protrusion with slight greater median focus where one can see an annular tear. A further slight posterior median protrusion of the disc can be seen at L5-S1. The intervertebral foramina are free. Joint ratios retained.”
On 09/2009 the patient underwent an orthopaedic specialist's examination which showed left lumbosciatic pain from L4-L5 and L5-S1 annular protrusion. The following treatment was advised: Tricortin 1000 vial IM 1 per day for 10 days ; Toradol vial IM 1 per day for 3 days; then Tachipirina (Paracetamol) 1000 1 every 12 hours for 4 days; then 1 a day for 4 days. Breg-type lumbar orthopaedic brace; medical posture gymnastics with caution; if pain persists epidural treatment following tests.” The same doctor explained verbally to the patient that, while the drug treatment was only palliative, surgery was not recommended also in view of her young age. He suggested her to try other therapeutic approaches such as ozone therapy for example, until she found the best treatment for her case.
As she did not receive a satisfactory response from the treatment, the patient visited another orthopaedic specialist on 11/2009 who advised the following treatment: - Deltacortene 25 mg at a dosage of 1 tab per day for 5 days, then ½ tab per day for a further 5 days; - Dobetin 5000 1 vial by oral way for 20 days; - Orudis R 1 tab for 10 days; Use of an orthopaedic brace. This doctor too did not recommend surgery stating that if the prescribed treatment did not have the required effect he would suggest ozone therapy at the end of November.
Despite the drug treatments underway, the patient still complains of strong pain in the lumbar region involving the entire left leg.
Comments: The medical history sent to me is limited, not including the exact type of pain (response to physical effort and rest), pain distribution and the neurological status. MRI pictures sent to me show low signal on T2 of the L4-S1 discs, some straightening of the physiologic lumbar lordosis and a high intensity zone representing an annular tear at the L4-5 level. There was also some disc herniation (bulge) at those levels. The L3-4 looks unaffected.
There are some points that can be drawn so fare:
1. I assume the patient has combined mechanical and Lt. radicular pain.
2. The pain lasts for about 6 months, unrelieved by conservative medical treatment and physiotherapy.
3. I have no information about risk factors for degenerative disc disease in this patient. The CT and MRI are of good technical quality, suggesting the patient is not overweighed. Early degenerative changes may indicate smoking as a possible risk factor. If this is true, smoking should be stopped immediately.
4. There is no indication for urgent surgery at this point. There are different types of "minimally invasive" procedures that may help this patient. First is "radiofrequency neurotomy" of the medial branch of the dorsal roots combined with pulsed RF of the DRG affected. Second type of treatment I considered in this case is "per cutaneous nucleotomy ("coblaion"). The levels to be treated depends on the pain distribution and as mentioned before, I don't have this data.
5. Surgery in such case of degenerative disc disease should include decompression and stabilization. It is indicated after failed conservative treatment and after at least 6 months. These terms are present in this case, therefore surgery should be considered.
6. Discography in controversial but I believe it should be performed to pinpoint the painful discs and not less important, investigate the L3-4 level.
7. In case surgery is accepted as the next step by the patient and her surgeon, I would suggest combination of decompression (lamitotomies, foraminotomies) at the affected levels with stabilization. On the L5-S1 I would prefer static fusion (probably TLIF entering disc space on the left). On the L4-5 level I would consider some type of dynamic fixation but not fusion.
8. Success rate differs between the treatment modalities mentioned above. In nucleotomy and RF the success rates are 65%- 70%. Those rates are relatively low but they are minimally invasive, very low complication rate and no irreversible outcome. Success rate for decompression and fusion is estimated around 80%-85% good results. This number differs according to different criteria used by surgeons and researchers. I don't have information about Italian centers performing those treatments.
9. It is very difficult to discuss "permanent medical cure" in degenerative disc disease. Following the "minimal invasive procedures" mentioned above, in considerable number of cases their effect tend to be transient. Surgery tend to give more "permanent" outcome but one should consider other discs that may get involved in the future.