Brief Answer:
Degenerative arthritic disease of the LUMBAR SPINE

Detailed Answer:
I've read your your information related to what the MRI study has shown regarding a broad central disc protrusion at L4/L5 as well as the other descriptions of degenerative arthritic disease of the lumbar spine suggestive of lumbar canal NARROWING (stenosis) as well as other compromises such as facet hypertrophy which is the equivalent of calcifications of parts of the vertebral bodies that can then, contact and irritate nerve roots as they exit or enter the spinal cord.

All of these changes can result in pain which as you've pointed out can be excessive and include the low back, the buttock, and even radiate into the leg. This is a very common picture indeed for patients who have the same type of lumbar spine arthritic disease as you do.

As far as injections for pain reduction purposes are concerned...it is very hard for me to accurately mark the exact level at which an injection should be given since I do not have the advantage of examining you in order to map out areas which appear to be more or less clinically involved in the problem. The anesthesiologist or pain management specialist usually will perform test doses of medication as a preliminary guide as to where best you may benefit from a full injection.

I wish I could say that I've seen great success with lumbar injections but in fact, it is highly variable with most cases I've seen reporting that the effectiveness of such procedures lose their robust effects after only several cycles.

On the basis of the MRI it seems that the WORST part of the lumbar spine from a deteriorative point of view is at the L4/L5 level. At the level there seems to be moderate to SEVERE FACET HYPERTROPHY (a significant amount of arthritic change) compared to only MODERATE central canal stenosis (narrowing) at L5/S1. The dermatomal correlate of nerves coming in and going out at that level have more to do with the most distant parts of the leg (back part of the calf and front of the leg just below the knee)as well as the sensation of the foot as opposed to the buttock or hamstring.

In other words, if it were my own case that appeared this way and I was truly a FAN of doing injections as a way of relieving pain then, I would perhaps opt for another injection at the same level as the first (L4/L5) because I feel that dermatomal level has much more likelihood of reducing pain IN THE BUTTOCK and HAMSTRING than doing an L5/S1 injection. I would also suggest you engage the doctor who is injecting in his/her opinion as to other alternatives to pain management for that sort of problem in the event that the injections begin to lose efficacy in the future.

I understand that in the past your buttock pain on the left was greatly relieved by an L5/S1 injection, however, that is slightly difficult to explain since the dermatomal anatomy of the buttock actually DOES NOT INCLUDE skin innervation elements of either L5 or S1. Those are, as I said, mainly located DISTANT from the buttock and more than anything are in the lower leg (below the knee) and in the foot.

It certainly does seem that your complaints and symptoms are pretty much right sided so I agree that the injections should be RIGHT SIDED.

If I've answered your concerns satisfactorily would you do me the largest of favors and CLOSE THIS QUERY with a few words of positive feedback? Please write back to me if other questions or comments at: www.bit.ly/drdariushsaghafi should arise and I will gladly answer.

This query has utilized 35 min. of research and response time on behalf of this patient.

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Brief Answer:
Thank you for your kind words of feedback.

Detailed Answer:
Perhaps it depends on which dermatomal maps you consult, however L5 really has nothing much to do with sensation of the buttock and S1 only innervates about the outermost 25% of the buttock region wrapping in a band almost posterolaterally down the leg....About 75% of the buttock is innervated and modulated by S2, S3, S4, and S5.....L5 and S1 roots really have much more to do with sensations below the knee. Steroid injections should really be focused and infused at the level oif the spinal column and even then, I highly caution people on steroids to not get lulled in thinking that is really an answer to anything....unless the major contributing cause was definitely coming from a specific level easily reached by the steroid injections.

I would not place injections at L5/S1 unless there were either EMG evidence of the spinal level or some other way of verifying that the pain was NOT at the level of the spinal column. In my opinion your best bet is NOT TO TAKE THE STEROIDS at full dose right now unless it is right over the L5 level.

If I've answered your concerns satisfactorily would you do me the largest of favors and CLOSE THIS QUERY with a few words of positive feedback? Please write back to me if other questions or comments at: www.bit.ly/drdariushsaghafi should arise and I will gladly answer.

This query has utilized 35 min. of research and response time on behalf of this patient.
Replied by Dr. Dariush Saghafi , 1 day ago

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Brief Answer:
Gluteal pain

Detailed Answer:
Thank you for the follow up clarification. Your wrote the following:

You mentioned not to take injection at L5 S1 level.

1. Is it because there is inherently more risk in taking injection at this level vs at L4 L5.

>>>> I am not not aware of any MORE or LESS risk at doing a block injection at the L4/5 level compared to L5/S1. To my knowledge there is nothing anatomically speaking that should make injections at either of those levels particularly risky. The spinal cord itself generally ends in my people at about the L1 or L2 vertebral level therefore, injecting anywhere below should be "equally risky."

I merely don't believe that an L5/S1 block will give you much relief since that is not the major dermatomal level that sensation from the gluteus is sub-served. However, in your particular case, perhaps you have a slight anatomic variant whereby injections at L5/S1 have given you very acceptable relief. So, perhaps based on prior experience this would be OK.

The dermatomes known to subserve MOST of the gluteus are S2-S5.

An L4/L5 block will tend to give you relief down the posterolateral aspects of the legs as well as the anterior portions below the knee and part of the plantar surface of the foot including the great toe region.

2. You mentioned not to take injection at L5 S1 level.

I counsel my patients that they should not receive steroid injections any more frquently than a couple times a year and only in the most extreme pain circumstances since steroids have a number of deleterious effects against tissues such as bones, ligaments, muscles, and tendons which if exposed several or more times a year could result in deterioration of the tissue and cause even more pain and discomfort as time goes on....not less.

If I've answered your concerns satisfactorily would you consider CLOSING THIS QUERY with statements of positive feedback? Please write back to me if other questions or comments at: www.bit.ly/drdariushsaghafi should arise and I will gladly answer.

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