Back Pain with Partial Sensory Leg Anesthesia
25-year-old male had an outbreak of sharp pain in the loin, and afterwards complained of partial sensory anesthesia in his leg. He has been given prescribed treatment that included blockades, magnetotherapy, and ultrasound massage with hydrocortison. He experienced back pain for the first time after lifting a heavy thing, and got a pain relief after taking a pain-killer and applying Finalgon ointment. After few months the pain reoccurred. The patient then got a MRT test and was prescribed Finalgon and Milgamma pills, but developed an allergy towards Milgamma. MRI shows streightning of the physiologic lumbar lordosis, moderate protrusion in the L5-S1 level and substential herniated disc at L4-5 level. The L3-4 looks like a mild to moderate bulge.
The patient asks about the conservative and surgical treatment options, the possible complications and the prognosis.
Age: 25 years old.
Being at home, the patient stood up from the chair and suffered a sharp pain in the loin. After this outbreak he kept on complaining of the partial sensory anesthesia in his leg. He consulted a doctor in a local hospital who asked him get the spinal tomography. Since June 5th up to now the patient has been given the hospital treatment. The treatment prescribed is as follows: blockades, magnetotherapy, and ultrasound massage with hydrocortison.
First time the patient experienced the back pain last year. This young guy lifted a heavy thing (a log) and immediately got a pain. After taking a pain-killer and applying Finalgon ointment (active substance: Nonivamide* +Nicoboxil*), he got a pain relief. In the end of December the pain reoccurred. The patient then contacted the hospital again, got a MRT test and upon the diagnosis, was prescribed Finalgon and Milgamma pills. But he soon developed an allergy towards Milgamma and stopped the intake of the pills. Until May he had had no outbreaks.
MRI images show low signal of the L3-S1 discs and some streightning of the physiologic lumbar lordosis.. The L5-S1 disc show a moderate protrusion to the right and the L4-5 level represent a substential herniated disc, mostly to the left. The L3-4 looks like a mild to moderate bulge.
Comments: The medical history sent to me is very limited, not including the pain distribution, neurologic status and response to the conservative treatment he received.
Proper treatment in this case is not simple and trivial due to his young age and the number of the affected levels. I'll try to draw some lines that may help planning the next therapeutic steps:
1. In case the patient has profound neurologic deficit (drop foot, sphincter disorders etc) – surgery is mandatory. I believe if this is the case, the information would have been sent to me in the case presentation.
2. Severe disabling pain uncontrolled by proper medical treatment attributed to the L4-5 disc herniation (Lt L5 radicular pain) can be treated by surgery. In my opinion surgery should include removal of the herniated disc from the canal and free fragments from the disc space. There is an option for dynamic stabilization (like DIAM) but this is an option and not must!. Opening and removing the L5-S1 disc is not mandatory and should be considered only if this disc is causing symptoms (e.g. rt. radicular pain in the S1 distribution). Surgery can be done as a minimally invasive procedure (endoscopic or microscopic) which has the benefit of easier and shorter recovery. On the other hand, the surgeon should be very experienced in doing these surgeries.
3. Performing a long fusion (L3-S1) in this case is not recommended, taking into account the patient's young age and the high incidence of adjacent disc disease expected (L2-3 etc).
4. In case the patient has no or only minimal neurologic deficit and responds to medical treatment (NSAID, analgesics) I would avoid surgery on this patient. Conservative treatment can also include epidural steroid injections.
5. There is a wide range of complications following spinal surgeries. The most common are wound infections (1%-3%), recurrent disc herniations (about 10%), scar formation, neurologic deficit, CSF leak etc. One should remember that removal of the free disc fragment will not solve a problem of back pain as long as fusion is not undertaken. As mentioned before, in case back pain is a major part of the clinical picture, dynamic fixation should be considered.
6. Long term prognosis is difficult to predict. I believe this patient should avoid doing profound physical efforts and avoid risk factors for degenerative disease of spine such as smoking. As to my opinion, after recovery period (with or without surgery) I would recommend gradual return to physical activities including non-competitive sport with proper medical follow-up.