Chronic Lower Back Pain





I am interested in your thoughts and suggestions that may be able to help a teenager with 2 years chronic pain from from Figure Skating and Running injury.

Chronic Lower Back and Left Leg pain for two years
. Level 7 to 10 Lower Back
. Only alleviated when lying down (level 3)
. Left high buttock pain - Stabbing pain when any pressure applied
. Sitting causes same pain
. Left leg outer, upper calf and thigh - Tingling sensation

New since surgery
. Pinching in low back when walk or run, extending a leg
. Left outer leg numbing during running
. Left leg tingles when walk


Treatments:
Surgery L5-S1 Artificial Disc replacement
Medication 1200mg Ibuprofin
All conservative therapies

Thanks

Dear Carmine,
A distressing story for any parent obviously, not to mention your daughter. You mention that she has had all conservative therapies, and I presume that would also include chiropractic.

Does the tingling and numb feeling extend ever, or did it in the beginning into the foot? Which toes? The first thought is that the outer leg is normally considered the L5 distribution. Whilst the L5/S1 disc can affect the L5 root, more usually it would cause the symptoms at the back of the thigh and calf, and side of the foot.

I'm wondering about the L4/L5 disc. On the Dropbox scans it appears normal, but only certain views are shown. Perhaps you'd like to have the pre-surgery MRI read by an independent radiologist.

Ask her please, off all medication for 24 hours to

1. Bend slowly and carefully forwards, then backwards and then to the side, and relate EXACTLY where the pain and numbness increases. So, four answers.

2. Sitting in a normal kitchen chair, would you straighten first her right leg parallel to the ground, lower it, and then the left leg; it's done passively; you lift the leg, not her. In both cases, EXACTLY what does she feel? Does straightening the right leg do anything in the left leg? Then repeat with the head flexed forward on her chest. Do it all gently as it can aggravate the condition.

3. Standing on the left leg, supported by a counter top, can she raise the big toe? And then can she raise her heel high off the ground without strain; on her toes.

4. Using a pin prick her leg and foot and compared sides; is there a difference? Where?

Looking forward to your answers; please be precise. And the dropbox x-rays.

Treat any information and opinion from Dr Google with caution! I cannot examine her first hand.

Dr B



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May 01, 2017
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Follow up tests
by: Anonymous

Answers to the above questions:
. Yes into the left foot but very lightly
. Left Toes: very lightly tingling, not very noticeable (counting from the big toe: toe 2 and 3)
. Left outer calf, numb when run, tingling when walking, nothing when lying down, tingling when sitting
. Worst is pinching in lower back when bend head and shoulders backward (extension)


Response to the 4 tests:
1. Standing Bending test
Standing: soreness Pain 4, low back bilateral
a. Forward: just a little stiffness, no numbness or tingling or pain
b. Backward: pinching pain in low back, level 7+, starts immediately when change from neutral standing position
c. Left side: pinching pain in low back, level 6, starts immediately when change from neutral standing position
d. Right side: pinching pain in low back, level 6, starts immediately when change from neutral standing position

2. Sitting test
Sitting (proper posture) soreness, Pain 3, low back, bilateral
Right leg: no change
Left leg: no change
Head forward
Right leg: no change (or ever so slightly)
Left leg: no change (or ever so slightly)

3. Standing, one leg
Stand on Left leg, raise big toe: Yes, no change
Raise heel: yes, no change
Stand on Right leg, no change
Raise heel, yes, no change

4. Pin test
Left leg, foot no difference
Right leg, foot no difference

Hello Carmine,
By and large this all good news; it suggests there is at this point no serious pressure on the sciatic nerve; however the tingling and numbness in the outer calf when sitting, walking and running still indicates nerve irritation. If it was seriously pinched, the sitting Flip test would have provoked tightness and pain in the calf, as would the standing bending tests.

The extension and lateral flexion pain in the lower back points to the facet joints at some level in the lower back; usually this would respond fairly quickly despite the chronic nature of her pain to gentle chiropractic manipulation.

The x-rays; here let me state categorically that I am not a qualified radiologist, however we had a very thorough training in radiology and I've been reading x-rays for 36 years.

Moderate L5-S1 disc narrowing. If you look carefully at the AP view you'll see the last rib arrowed on the left, and to a lesser extent on the right; they are smaller than usual and what is known as 'rudimentary ribs'. This vertebra in my opinion is the true L1, even though it has ribs. That means that she has six lumbar vertebrae, a fairly common variant known as a lumbarisation of the first sacral segment; the lowermost disc is almost invariably narrowed.

The disc lesion may well have been at the level above, and not what is being called the L5-S1 joint. The MRI should reveal that.

So that narrowing of the disc is not due to injury or disc disease; it's quite normal with a lumbarised S1.

Left convex scoliosis. There is no disagreement here, but I would call a Cobb's angle of 15 degrees moderate rather than minor. A matter of opinion.

What's not mentioned is the significantly short left leg; that is the cause of the pelvic tilting and scoliosis, and should be addressed.

Standing and walking are very often difficult with a short leg.

What's also not mentioned is a Schmorl's node at L1, or T12 depending on the lumbarisation issue. What is uncertain is whether this is traumatic, or an incipient Scheurermann's. The latter occurs mainly in the thoracic spine, and far less commonly in the lumbar spine where it is more problematic. There is possibly another at the superior margin of the sacral, but not clearly seen.

Does she have any groin pain and can she pull her knee to the chest with no discomfort on either side? There is just a suggestion of a Pincer deformity shown in the L hip, but this may be clinically completely insignificant.

All of this frankly you should weigh carefully, but perhaps a little dubiously; Dr Google has not had the opportunity to examine your daughter, and that makes all the difference. I consider it my role simply to be the Devil's Advocate; seeing things from a different perspective sometimes sheds considerable light.

I would recommend that you have a simple, inexpensive lift placed in her left shoe which she really should wear at all times; it's a nuisance, especially with summer coming on, but I think important. It takes considerable skill to know how many millimetres to add, and whether it should be just under the heel, or the whole foot.

And she should start doing some simple lumbar exercises on her bed EVERY morning before arising, and perhaps several times a day. Anything involving extension should be very gently done. There are some at Chiropractic Help, found in the navigation bar, but perhaps better given and directed by a local person.

Then after a month or two evaluate whether there is any progress or not.

I hope all this contributes, Carmine. Let me know in a month or two how she's getting on please.

Dr B





Apr 25, 2017
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by: Barrie

A question: have the words Scheuermann’s and short leg ever been mentioned? Could I please have the radiologist’s report of these X-rays please. Has Paige ever had significant trauma to her lower back?

Dr B

Scheumann. No

One dr did suggest leg length discrepancy. But not conclusive nor did we ensure the shoe had the lift added to it.
Yes. From figure skating. Repeatedly.
We think it was from age 12.
She stopped figure skating for 2 months then started again.

Then it surfaced again as back pain at age 14 through soccer. Quit figure skating and soccer - started running intensely. Then the major incident occurred from a race. May 15 2015.

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