Myofascial back pain in a patient diagnosed with mild disc degeneration
Short summary
The patient is a 52 year old male, who is suffering from backache and carried out imaging tests of the lumbosacral spine. Plain x-rays showed mild left scoliosis without rotation, sclerosis at the L5S1 facets, marginal osteophytes, and decrease in the height of the L5S1 disc space.
MRI scan showed mild central disc bulges at L23 and L34 without significant impingement on the dural sac. There is a mild central and left-sided disc bulge at L45 which slightly narrows the left L4 foramen. There are Schmorl's nodes at L4 and L1, and there is a hemangioma in the body of L1. There is a Tarlov cyst (arachnoid cyst) on the right S2 nerve root.
The physiatrist found normal strength and sensation and no spine tenderness.
The neurosurgeon found nothing neurological in nature and in his opinion the MRI shows nothing particular unless for some moderate protrusions and two vertebra angiomas, which have no pathological meaning. His diagnosis is dorsal paravertebral contracture, so he recommend local ice and massotherapy.
Patient's questions
1) Do you agree with the therapeutic suggestions of the two specialists? Do you have any other therapeutic supplements?
2) Why didn't the physiatrist and neurosurgeon consider the two disk hernias of the first lumbar segment and the two protrusions of the second lumbar segment? Do you think some treatment, even preventive in nature, is necessary to prevent worsening of the clinical picture in the future?
Medical Background
52 years old male, that following the onset of algic symptomatology of the spine carried out the following lumbosacral spine diagnostic tests:
- X-ray of lumbosacral spine - 2 projections -
“slight left lumbar convex scoliotic attitude on wide scale without coarse rotation of the metamers on their vertical axis. Attendant diffuse moderate signs of arthrosis, more evident at the lumbosacral passage, marked by sclerosis of the articular facets, sharpening of the profiles and tendency to marginal osteophytosis. Moderate reduction of size of the L5-S1 disk space".
- Lumbosacral Spine NMR -
"Small osteoangioma in the L1 soma. Diffuse arthritic abnormalities at the somatic marginal branches and articular facets. The spine channel size is within normal limits. Subligament median disk hernia at L2-L3 that modestly impresses the dural sac in the center. Small median disk hernia at L3-L4 that modestly impresses the dural sac in the center. The protrusion also pushes into the foramen, which also reduces the epidural fat around the roots of L3. Posterior disk protrusion at L4-L5 and more evident at the intra- and extra-foramen site, with slight impression on the dural sac and reduction of the epidural fat around the roots of L4 that appear reached, but not grossly compressed. Posterior disc protrusion at L5-S1 and intra- and extra-foramen more evident to the right, where the root of L5 arrives from this side. Radicular arachnoid cysts at S1-S2 in right paramedian area. Cone and cauda normal. Schmorl nodules in the somatic plates of L4 and in the inferior somatic plate of L1."
The patient was then sent to physiatric and neurosurgical specialist assessments, the findings of which are reported:
- Physiatric examination:
Objective examination: no significant deviations of the spine. Motility uncompromised. No signs of spinal pain. Strength and sensitivity uncompromised. DIM at lumbar level.
Conclusions -> Postural back pain, so we recommend: Cycle of muscle relaxant massotherapy (10 sessions); Expose 100 mg 1 tab in the evening for 5 days; at least two weeks of working out dorsal, abdominal and gluteal muscles at the gym before resuming sports activity (golf).
- Neurosurgical examination:
The specialist finds nothing neurological in nature; he also refers to the NMR carried out (reported above) that, in his opinion, shows nothing particular unless for some moderate protrusions and two vertebra angiomas, which have no pathological meaning.
Conclusions -> evidence of dorsal paravertebral contracture, so local ice and massotherapy are recommended.
Medical opinion
The patient is a 52 year old man with back pain. I am not given a description of the character or location of the pain, nor is there any mention of radicular symptoms in the legs.
Plain x-rays were read as showing mild left scoliosis without rotation. There was sclerosis at the L5S1 facets, marginal osteophytes, and decrease in the height of the L5S1 disc space.
The MRI scan, which I read, showed mild central disc bulges at L23 and L34 without significant impingement on the dural sac. There is a mild central and left-sided disc bulge at L45 which slightly narrows the left L4 foramen. The conus medullaris and the cauda equina are normal. There are Schmorl's nodes at L4 and L1, and there is a hemangioma in the body of L1. There is a Tarlov cyst (arachnoid cyst) on the right S2 nerve root.
The physiatrist found normal strength and sensation and no spine tenderness. The neurosurgeon found "nothing neurological", which I take to mean no symptoms or physical signs of radiculopathy.
The diagnosis is myofascial back pain, which probably relates to the x-ray and MRI findings of mild disc degeneration. These findings, mild disc bulging, loss of L5S1 disc height, and Schmorl's nodes, are normal for the patient's age, and they do not correlate well with back pain. I do not see any scoliosis on the scout films for the MRI, so I do not believe that what was seen on the plain films (probably taken supine) is significant. Hemangiomas in the bodies of vertebrae are very common in the population. They are benign, do not increase in size, do not spread, and do not cause pain. Arachnoid (Tarlov) cysts in the sacral spine are also common and do not cause symptoms except in very rare circumstances.
Given the lack of major structural problems in the bones or discs, the pain can be expected to spontaneously abate and disappear with time. I agree with the physiatrist's prescription for physical therapy aimed at core strengthening, lower extremity stretching, and massage. These exercises, and attention to achieving and maintaining normal weight (body mass index), with gradual return to customary activity and sports, are the basis of prevention of future episodes of pain. I do not find any indication for injections or for surgery with this history and these MRI findings.
