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What Do These X-ray Findings Indicate?

Posted on Wed, 8 Jun 2016

Question: My mother is 89. She has degenerative spinal disease. I can attach recent xrays. She wont qualify for an MIR. She typically has to sit after 15 minutes standing - walking is a bit better. Recently her pain has increased signficantly. It was originally centred in the lower lumbar area but now for the last few days - its below the hip bone, concentrated in the right upper buttock area. Initially upon standing - she has about a couple of minutes where acute pain sets in - she had a bit of radiating pain down (once) but has difficulty putting weight on it at times too. She uses a walker in the house. Morphine hasnt helped (1/2 pill gives her dizziness). A tens device/voltaren gives brief relief as a corset helps relieve some of the pain. Her physiotherapist believes its some facet nerve irritation but hes not certain either. She also had facet nerve injections a few years ago - gave her brief relief and nerve ablation did not help

Answered by Dr. Aashish Raghu (19 minutes later)

Brief Answer:
Kindle attach the xrays. She may need surgery for suspected slip disc.

Detailed Answer:
Hi there.

Thanks for the query.

Your mother could be having degenerative spinal Osteoarthritis which includes facetal arthritis. There may be associated slip disc which is why she has radiating pain down her leg.

It would be best to get the MRI done because the exact cause of her pain can be found and the right treatment planned. A slip disc can be seen if present, on an MRI and if required micro surgery can be planned to remove this disc that is pressing on her nerves.

She needs physiotherapy to increase the strength of her lower back muscles, application of moist heat to the regions of muscle spasm, avoiding bending forwards or lifting weights. She can continue TENS and also try IFT, Ultrasound therapy. Repeated facetal joint injections can offer relied for now until she gets an MRI, if possible.

Also she will be having Osteoporosis and severe bone weakness so sure needs calcium and Vitamin D supplements and diet rich in protein and Calcium. Sunlight exposure is also needed.

I hope I have answered your query.

I will be available to answer your follow up queries.

Regards,

Dr. Aashish Raghu

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Follow up: Dr. Aashish Raghu (46 minutes later)

I am having difficulty posting the xrays - Can you view them on the other question posted to the radiologist. My mother wont qualify for an MRI or surgery. She is too old in a public health care system where people abuse it as its free. She has applied topicals and wearing a lumbar support which is helping her. Its unfair for her to suffer like this

Answered by Dr. Aashish Raghu (4 minutes later)

Brief Answer:
Needs Vitamin D and Zoledronate injections

Detailed Answer:
Thanks for the reply.

I have viewed the xrays on your previous question on this Forum.

Your mother has severe degenerative spine with scoliosis and secure Osteoporosis.

Radial surgery may not benefit much in such cases. Her bone mass needs to build up, so kindly follow the advice as mentioned in my post to you. She may also need weekly Vitamin D injections for 6 weeks and Zoledronate injections yearly to prevent Osteoporotic fractures. These shall also reduce the pain and suffering.

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Follow up: Dr. Aashish Raghu (41 minutes later)

Why would the pain be acute in the lumbar area one week ago and then shift centralized into the buttock quadrant sharply. She had benefit from spinal traction a few years ago. Now they have more modern decompression tables that guage muscle resistance - could she try that. She takes 1000IU vitamin d daily - how is that clearly defined she needs extra supplements or injections - is this borderline or significant to be done. I am in Canada and it appears XXXXXXX is more advanced

Also she had facet injections a few years ago - they provided temporary relief for a few days. They attempted an ablation which had no effect

Answered by Dr. Aashish Raghu (10 minutes later)

Brief Answer:
She now has Sciatica possibly due to slip disc

Detailed Answer:
The shifting of the pain from the lumbar area to the buttock indicates nerve root irritation or Sciatica. An epidural steroid injection will definitely help her.

She needs avoid 700-800mg of calcium a day and 400-800IU of Vitamin D a day. It is best to get her Calcium and Vitamin D levels tested because in old age and taking frequent medication the calcium absorption may be inadequate this not getting into her boobs as desired, besides taking good amount of 1000IU a day.

Facetal infections may not really help at this stage because she now has Sciatica. She can take Tablet Pregabalin 75mg at night for a month for the symptoms of Sciatica.

Above answer was peer-reviewed by : Dr. Vaishalee Punj

Follow up: Dr. Aashish Raghu (24 minutes later)

It takes over a year to get a referral to a pain specialist.
They stated an epidural steroid injection would only be temporary relief

They dont do mineral testing normally in the blood. Family doctor stated - a bone test would be more accurate. I doubt they will do the latter. My incurred three falls in the last year -2times on a faulty treadmill and once with a coat rack.
She had no acute breaks at the time and walked away. I am hoping that regardless of her spinal arthritis - her bones are not that brittle.
Her main pain is the centralized sharp stabbing pain in the right buttock quadrant.
She has no regular radiating pain into the lower leg.

I realize more and more how primitive of a nation I live in. She should be getting an MIR. You never commented on the spinal traction either!

Answered by Dr. Aashish Raghu (6 minutes later)

Brief Answer:
Spinal traction discouraged. Needs MRI and Doppler

Detailed Answer:
Spinal traction is not a usual or safe method to treat degenerative spinal conditions for the fear of a dreaded side effect of paralysis. It is an ancient practice and is usually frowned upon by today's Spinal surgeons but may be found in a Chiropractic's office.

The pain in the buttock that radiates to the limb is Sciatica in most instances. You can get a Doppler scan to rule out any clots formed in the major veins in the lower abdomen which can also cause buttock pain.

An MRI is essential to find out the cause for the Sciatica.

Above answer was peer-reviewed by : Dr. Naveen Kumar

Follow up: Dr. Aashish Raghu (1 hour later)

You dont read the information thoroughly either.
She has the predominant pain focused in the right buttock primarily - sharp piercing stabbing pain where she doesnt have it radiating pain downwards but rather putting weight on it at times creates more pain in the glutes.

Answered by Dr. Aashish Raghu (1 hour later)

Brief Answer:
Needs Doppler and MRI

Detailed Answer:
Thanks for your reply.

This needs urgent evaluation to rule out Iliac vessel clots which can cause buttock claudication. Needs Doppler study.

Sciatica may not be typical in her case which needs an MRI as well.

Above answer was peer-reviewed by : Dr. Naveen Kumar

Follow up: Dr. Aashish Raghu (13 minutes later)

She takes a daily blood thinner for atrial fib - the area is not warm either

The pain also subsides when sitting down!

Answered by Dr. Aashish Raghu (5 minutes later)

Brief Answer:
Possible hip arthritis, needs Pain Medicine consult

Detailed Answer:
Thanks for your reply.

Hip joint arthritis could be considered amount the differential diagnosis for the buttock pain which relieves on sitting down. Local hot pack application could help. Avoidance of kneeling, squatting, cross leg sitting shall offer relief. It would be best to get her examined by an Orthopaedic surgeon to evaluate stage of arthritis of any, degree of nerve compression if any as well.

She may need a Pain Medicine consultation to up her medication dosage or make a change that would offer her relief. Opioid medication would suit fine.

Above answer was peer-reviewed by : Dr. Naveen Kumar

Follow up: Dr. Aashish Raghu (17 minutes later)

She has been taking 0.5mg morphine the last couple of nights.
No relief and she has been sleeping much more through the day.
Heat would irritate a nerve. As I mentioned - the pain was acute in the spine and now moved into the glute area. An xray will not show anything meaningful and she wont get an MIR. I do believe its a compressed nerve and since she gets relief from sitting, her leg muscles (hip flexors) are getting tighter

ANyhow - you have provided your insight as best as you can

Answered by Dr. Aashish Raghu (30 minutes later)

Brief Answer:
Morphine dose adjustment

Detailed Answer:
Thanks for your reply.

She may need to get her Morphine upped a bit to help tide the pain for now.

Do follow up with me on her progress.

Thanks and regards.

Dr. Aashish Raghu

Above answer was peer-reviewed by : Dr. Naveen Kumar

Follow up: Dr. Aashish Raghu (13 minutes later)

SHe is already drowsy as it is with 0.5mg

Answered by Dr. Aashish Raghu (13 minutes later)

Brief Answer:
Pregabalin

Detailed Answer:
She may done improvement with Tablet Pregabalin 75mg at night for a month. Please consult her Ductile regarding this as it is not a drug available over the counter.

Note: For further queries, consult a joint and bone specialist, an Orthopaedic surgeon. Book a Call now.

Above answer was peer-reviewed by : Dr. Naveen Kumar