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Have Central L4/L5 disc herniation. MRI report says right sided annular tear. What does this mean?

Nov 2013
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Hi, more than two years ago I injured my back while lifting too heavy, it caused a disc herniation in my L4/L5. The symptoms have been mostly burning feet/legs. The MRI report showed (roughly translated): "slightly dehydrated 4th lumbar disc with broad right sided, partly foraminal annular tear tangent right L5 root in recess. There is also a small central disc herniation in the 4th lumbar disc without root affection. Good space conditions in the root canals". I haven't had much progress over these two years. I encountered some tingling/vibration in my perineum a few months ago with tailbone pain as well, then did a new MRI which showed no change at all. A couple of weeks ago I bent down to the sink while squeezing my legs together, and instantly felt pain in the area, like a wound, a little on the right side, matching the MRI report? I have had more back pain since then, a sore feeling, sometimes feels like the wounded area is vibrating, and recently I encountered muscle weakness in my right thigh (above the knee), and now also some weird tingling in one of my right toes (the second one), and from time to time some muscle pain in areas of my right leg, but the weakness has disappeared for now. I am seeing a chiropractor for treatment, who checked my reactions, reflexes etc, was ok. He said I may have caused the disc herniation to become broader. Since I have a Central L4/L5 disc herniation, I worry about Cauda Equina Syndrome. But the MRI report says I have right sided annular tear, and my recent symptoms are more right sided. What does that mean? Is it better? Based on my story, would you recommend a New MRI? Am I in danger of developing CES?
Posted Sat, 7 Dec 2013 in Brain and Spine
Answered by Dr. Sudhir Kumar 4 hours later
Brief Answer: My reply is below. Detailed Answer: Hi, Thank you for posting your query. First of all, I would like to reassure you that you have very little chance of developing caudal equine syndrome (CES). This is because, for CES to develop, there should be compression of several lumbar and sacral nerves on both sides (typically from lumbar 4, lumbar 5, sacral 1-3). CES generally develops after road traffic accidents, infections, tumours, etc. In your case, there is disc herniation and is pressing on one or two lumbar nerves (L5 and may be L4), more on the right side. Your symptoms can be explained by your current MRI findings. At the present time, you should continue physiotherapy. In addition, medications such as pregabalin or gabapentin capsules would be helpful in relieving neuropathic pain, tingling, vibrations, etc. You should avoid forward bending and lifting heavy weights. I expect improvement in 4-6 weeks with these measures. If you do not get better, you may repeat the MRI and consider a possibility of epidural injections. I hope it helps. Please get back if you require any additional information. Wishing you good health, Dr Sudhir Kumar MD (Internal Medicine), DM (Neurology) XXXXXXX Consultant Neurologist Apollo Hospitals, Hyderabad, India Click on this link to ask me a DIRECT QUERY: My BLOG:
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Follow-up: Have Central L4/L5 disc herniation. MRI report says right sided annular tear. What does this mean? 21 hours later
Thank you so much for this reassuring response. With such a long back ordeal, I have become more anxious, always fearing the worst. And reading about CES on the internet does not help at all. Since central disc herniations are not that common, and from what I read CES only occurs in those cases, then I automatically assume it may happen to me. I am aware of red flags, and I know how to act upon them. But then I have also read about cases of "incomplete CES" or "slow onset CES", which sounds more difficult to diagnose. Would it for instance be possible to suffer impotence as only symptom of CES or would I definitely notice if something was wrong early on? Bladder/bowel problems I would discover very fast, but not necessarily erectile dysfunction. Thanks again for your help.
Answered by Dr. Sudhir Kumar 2 hours later
Brief Answer: Thank you for getting back. Detailed Answer: Hi, I can understand your concern and anxiety with so much information available on internet. However, I would like to reassure you that slow onset and progressive caudal equina syndrome occurs with tumours, infections, etc, which can worsen over time, and not with injury, as the injury is a one-time event and not a progressive one. Also, erectile dysfunction can not be a sole symptom of CES, as it is generally associated with bladder and bowel symptoms, as the nerves involved in all the three functions are the same. I hope it helps. Best wishes, Dr Sudhir Kumar MD DM (Neurology)
Above answer was peer-reviewed by
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