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Suggest treatment for severe lower back pain

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Posted on Mon, 18 May 2015
Question: Severe lower back pain in 31 year-old female when moving in bed at night and standing from a sitting position. MRI found the following: "at the level of L4-5, there is at least mild desiccation of the disk. There is moderate to significant loss of disk height. There are degenerative changes of the endplates. There is a small circumferential disk osteophyte carp lex. A superimposed small central disk bulge is seen. There is mild narrowing of the caliber of the spinal canal. There are mild facet joint degenerative changes bilaterally. There is mild to moderate bilateral neural foraminal narrowing. L4 nerve roots exit cleanly bilaterally."
Conserative measures have so far failed (osteopathy, physiotherapy, medications)
doctor
Answered by Dr. Sudhir Kumar (12 minutes later)
Brief Answer:
Can go for epidural injections.

Detailed Answer:
Hi,

Thank you for posting your query.

I have noted your symptoms, MRI spine findings and treatment tried so far.

As per the report, there is bulging of discs, leading to pinched nerve in the lower back.

Initial treatment has been correctly done. I presume you have already tried pregabalin and gabapentin capsules, and they have failed in relieving the nerve pain.

At this stage, the best option is to go for epidural injections. This is quite effective and relieves pain in most people.

I hope my answer helps. Please get back if you have any follow up queries or if you require any additional information.

Wishing you good health,

Dr Sudhir Kumar MD (Internal Medicine), DM (Neurology) XXXXXXX Consultant Neurologist
Apollo Hospitals, XXXXXXX XXXXXXX
Click on this link to ask me a DIRECT QUERY: http://bit.ly/Dr-Sudhir-kumar
My BLOG: http://bestneurodoctor.blogspot.in


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Sudhir Kumar (12 minutes later)
Thank you for such a rapid response, Dr. XXXXXXX I do have two follow-up questions.
1) Could the osteophyte complex play into the whole pain thing? I did a bit of research into the matter and it seems that it could possibly be helping making the disc bulge out?
2) If the nerve is what is causing pain, is it normal then that the MRI reports says that the nerve roots exit cleanly bilaterally, and that there is no radiating pain in my legs?

To answer your questions, yes, I have tried pregabalin, but the intial dose was too high (it made me dizzy until afternoon the next day), and this new dose seems too low. The doctor has me on T3s during the day, and Percocet at night (as the T3s cause me insomnia).

Thank you again
doctor
Answered by Dr. Sudhir Kumar (13 minutes later)
Brief Answer:
Osteophyte complex can contribute to the pain.

Detailed Answer:
Thank you for getting back.

I agree that the nerve compression is not severe as per the MRI, and hence, surgery is not needed. Also, lack of radiating pain in legs also confirm that the nerve compression is not severe. Minor compression of nerves, sometimes, can not be well appreciated on the MRI.

Disc osteophyte complex causes narrowing of the foramina, and thus, contributes to the pinching of nerves.

I usually start pregabalin (lyrica) at a dose of 75 mg once daily at night and increase by 75 mg per week to a dose of 150 mg two times daily, or until pain relief is achieved. If a high dose is started, dizziness is quite common.

Best wishes,

Dr Sudhir Kumar MD DM (Neurology)
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Sudhir Kumar (20 minutes later)
It's strange though because I know what real pain is. I've had large kidney stones and have had natural childbirth. This back pain is among those (although not consistent, thankfully). It doesn't seem possible to me that the nerve impingement is so minor considering the amount of pain it produces. Is it possible that the nerves appear okay on the MRI because my pain only occurs when I am in certain positions/ movements, and I did not have any pain while the MRI was being done?

I also have serious low back stiffness in the mornings for about one hour. I can't really get dressed, have much trouble taking the baby out of his crib, etc. It's like I can't move my lower back or it will really hurt. I also get that stiffness after standing up for long periods of time, and it is only relieved if I sit, or if I lean on, say, a counter, with a foot up on a stool. Is this still consistent with the nerve/ bulging disk issue?

Thirdly, I also have a herniated disk at T6. I almost always have moderate/ severe discomfort in that area (more or less between the shoulder blades). It feels like extreme muscle tightness but I cannot get rid of it. It will hurts even when getting a massage. Most research I've done says that T-level herniations don't typically hurt. Is this possible?

doctor
Answered by Dr. Sudhir Kumar (9 minutes later)
Brief Answer:
MRI findings may not correlated with degree of pain.

Detailed Answer:
Thank you for getting back.

I can understand your dilemma. MRI findings are "minor" and pain is "severe". So, is the MRI "wrong" or is there "some other cause" of pain that we are missing?

As I mentioned earlier, I see several patients with the "MRI-symptom mismatch". In fact, I have seen patients with nerve compression on one side and the pain on the opposite side. This is because, the pain depends on the posture, movements, work schedule, rest/no rest status, and several other factors. MRI shows the picture of the nerves at "one particular time" and in "one particular body posture".

In my experience, the role of MRI is two-fold:

1. Select cases that are likely to benefit from surgery, where the nerve compression is severe, and there is a perfect match of MRI and pain symptoms,

2. Detect or rule out other causes of back pain, such as infections (tuberculosis is common in India), cancer, osteoporosis, fracture, etc. In your case, all these causes are excluded. So, there is no other cause of pain.

I hope it helps you understand a bit the way I think.

Best wishes,

Dr Sudhir Kumar MD DM(Neurology)
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Sudhir Kumar (4 minutes later)
I also have serious low back stiffness in the mornings for about one hour. I can't really get dressed, have much trouble taking the baby out of his crib, etc. It's like I can't move my lower back or it will really hurt. I also get that stiffness after standing up for long periods of time, and it is only relieved if I sit, or if I lean on, say, a counter, with a foot up on a stool. Is this still consistent with the nerve/ bulging disk issue?

I also have a herniated disk at T6. I almost always have moderate/ severe discomfort in that area (more or less between the shoulder blades). It feels like extreme muscle tightness but I cannot get rid of it. It will hurts even when getting a massage. Most research I've done says that T-level herniations don't typically hurt. Is this possible?
doctor
Answered by Dr. Sudhir Kumar (3 minutes later)
Brief Answer:
Muscle spasm is very common.

Detailed Answer:
Thank you for getting back.

Muscle spasm and stiffness are quite common with bulged/slipped discs. This requires a lot of physiotherapy- such as IFT/ultrasound, etc. Application of ointments such as ketorolac or diclofenac gels are also useful. In some cases, I also use muscle relaxants such as mobizox (chlorzoxazone).

Best wishes,

Dr Sudhir Kumar MD DM (Neurology)
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Suggest treatment for severe lower back pain

Brief Answer: Can go for epidural injections. Detailed Answer: Hi, Thank you for posting your query. I have noted your symptoms, MRI spine findings and treatment tried so far. As per the report, there is bulging of discs, leading to pinched nerve in the lower back. Initial treatment has been correctly done. I presume you have already tried pregabalin and gabapentin capsules, and they have failed in relieving the nerve pain. At this stage, the best option is to go for epidural injections. This is quite effective and relieves pain in most people. I hope my answer helps. Please get back if you have any follow up queries or if you require any additional information. Wishing you good health, Dr Sudhir Kumar MD (Internal Medicine), DM (Neurology) XXXXXXX Consultant Neurologist Apollo Hospitals, XXXXXXX XXXXXXX Click on this link to ask me a DIRECT QUERY: http://bit.ly/Dr-Sudhir-kumar My BLOG: http://bestneurodoctor.blogspot.in