Left lumbosciatic pain from L4-L5 and L5-S1 annular protrusion
Short summary
The patient experienced an episode of lower back pain while carrying home shopping bags. Her family doctor diagnosed a “left lumbosciatic pain” and prescribed injections with vials of Orudis and Voltaren. The treatment resulted in temporary remission, therefore the patient started a new treatment regiment of Indoxen and Bentelan + acupuncture treatment which was partially beneficial.
At the end of the aforementioned treatment the patient experienced a total remission of symptoms for 2 months, when the lumbar pain returned spreading to the left leg. Further drug therapy was prescribed (voltaren+ Muscoril, and later Indoxen). The patient underwent a Lumbar-sacral NMR scan examination, which showed that the origin of the left lumbosciatic pain resulted from L4-L5 and L5-S1 annular protrusion.
Patient's questions
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?
3) Prognosis?
Medical Background
The patient experienced an episode of lower back pain while carrying home shopping bags. Her 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. A CAT scan was carried out on the lumbar-sacral spine.The family doctor established a new 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 2nd, 2009 while the lumbar pain returned spreading to the left leg, and the level was more intense than the previous episode. She visited 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. The patient underwent a Lumbar-sacral NMR scan examination which showed no central stenosis. At L4-L5 there was a slight circumferential protrusion with HIZ in the annulus. A further mild central protrusion of the disc was seen at L5-S1.
Later that same year the patient underwent an orthopaedic consultation and was diagnosed as left lumbosciatic pain from L4-L5 and L5-S1 annular protrusion. She was treated by Tricortin 1000 vial IM 1 per day for 10 days, Toradol vial IM 1 per day for 3 days, Tachipirina (Paracetamol) 1000 1 every 12 hours for 4 days and then 1 a day for 4 days. Breg-type lumbar orthopaedic brace; medical posture gymnastics with caution. The patient was advised that if pain persists, epidural treatment is recommended. Surgery was not recommended also in view of her young age. Another Orthopedic surgeon advised different medical treatment and suggested that if this fails, ozone therapy should be tried. Surgery was not recommended.
Despite the drug treatments, the patient still complains of strong pain in the lumbar region involving the entire left leg.
Medical opinion
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.
