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What causes facet arthropathy?

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Posted on Fri, 15 May 2015
Question: Hello doctor, I recently went through an MRI for my lower back pain. The report says,
1.     Bulging annulus with early facet arthrosis seen at L4-L5 level narrowing the spinal canal and slightly indenting the thecal sac.
2.     Right Para central and foraminal minimal disc protrusion seen at L5-S1 level narrowing the spinal canal, lateral recesses and compressing the thecal sac and descending S1 nerve root ( right side)
3.     Bulging annulus seen at C3-C4 and C4-C5 levels narrowing the spinal canal and slightly indenting the cord surface.
My neurologist said that I have 2 options where I have to undergo for tractions, steroid injections or if that doesn’t work then I have to undergo a surgery. I am 25yrs old Female, unmarried so my parents are worrying about using steroids or with surgery. So can you explain if my problem is serious and what treatment can I opt for? Thanks for the reply
doctor
Answered by Dr. Pradeep Vitta (1 hour later)
Brief Answer:
Need a few details about the lower back ache to recommend a regimen

Detailed Answer:
Hi,

I have gone through your complaints and need you to elaborate on a few more details mentioned here before I suggest a line of treatment and, if your problem is serious or not. It all depends on the extent of symptoms. Since when has the pain been there; I mean describe from the initial episode, and then its history of progression or regression. Also does the pain just stay in lower back or does it go down the thighs and legs to the feet? Any weakness or numbness or tingling sensations in the thighs, legs, feet? I also want to know if you have any pain in your neck radiating to your hands too since the cervical spine MRI shows there is mild indentation on the cord.

As far as the MRI report goes, it shows facet arthropathy, basically meaning the joints where two vertebrae stick to each has some inflammation. This can cause irritation to the nerve coming out and thus causing your problems. Now generally if the physical examination confirms the findings of the MRI, there is a very minor procedure called facet block injection, which in my opinion can take care of the problem. Now let me tell you what the injection is. Yes it contains steroids, but let me tell you that not all steroids are dangerous. They are dangerous depending on how long you take them and not on what dosage you take them. So certainly steroids are life saving when there is spinal cord injury and they are generally given once unless and until the pain recurs in which case it will recur after a period of 3-6 months and it is all variable. So a single shot of steroid will do you no harm, rather the benefits far outweigh the risks. Along with the steroid, they also will have minute amounts of local anesthetics which will numb the nerve irritation and thus benefit you.
Traction has been proven to be not all that helpful but surely you can give it a try. Some find it helpful some don't. But one thing I would advise you to do once the pain dies down, is to regularly swim. Once you strengthen your back muscles and neck muscles, they get firm enough to hold all the vertebrae in position and thus defend the nerves from irritation and compression. You should do that only after the pain has gone down. Also I think you should start taking Tylenol for the pain, thrice a day if it is severe. If that doesn't help go for local ultrasound and interferential therapy which will relieve the pain temporarily. They are all non-invasive.
I would also suggest to see a spine surgeon for his opinion. He would be in a better position to do the requisite physical exam and decide the best course as the physical exam dictates.

Hope this helps, of course if you have any queries or clarifications, do get back here and I will clarify them for you.

Regards,
Pradeep
Above answer was peer-reviewed by : Dr. Pradeep Vitta
doctor
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Follow up: Dr. Pradeep Vitta (1 hour later)
Thank you for the reply sir, and I will elaborate the details as per your need. My back pain starts in 2013 december wher i felt sharp pricking pain, numbness at centre point of my back and it started burning and spreading to my thighs when it got worse in April 2014 so I have been instructed to do exercises from my physician. Then after two months, I was feeling better but in between i stopped doing exercises from last year. Again from february 2015, I experienced the pain at lower back so I started doing my exercises but my pain has shown no difference. Before one week, I got severe back pain which lead me to take complete rest and i was not able to move my body which brought pain whenever i try to sit or got up or lie down etc. So I went to the doctor who told me to take MRI and Emg test. At present I have pain in my lower back only if i bend down or give stressful works for myself. But the problm is i developed numbness from last week. I am not able to sit more than 15min. numbness is more vulnerable than pain. starts from my lower back and spreads till tailbone. and am having pain in tailbone too. cervical problm starts in 2011 but the pain i had it only for 4-5 times in these years. It was a stabbing pain but was not radiating to shoulders or arms. but it lasts for 3days only in one year. now it rarely occurs if i bow down my head and do some works for long time where i used to have sharp pain. but that is not bothering me a lot. my doctor said that i can have only 5-6 steroid injections which won't give many side effects. bt i read in web as many people complaining about over weight as the major side effect for steroid even within 2 injections? that is why i am very scared to choose both options(surgery or steroid) I have used steroid ointment before 2 months diprovateplus in my knees for rashes prescribed by my dermatologist. but it gave me a side effect of eye stye and a major boil in my leg which took one month time to cure bcs it affects my bone and still i have very slow growth of skin. that is why i am scared to use steroid and that too as injection. I am already 53 kgs and 152cm height and unmarried so worrying about the putting weight. otherwise i don't have blood sugar and all the tests were normal. I am already having pimples and pcod problem and pms too.
doctor
Answered by Dr. Pradeep Vitta (41 minutes later)
Brief Answer:
Can you tell me what the EMG report shows?

Detailed Answer:
Hi,

I think the radiculopathy you are having is getting aggravated. The presence of numbness, and pain that restricts your time to sit for 15 minutes too is not a very good sign. It means the nerve is getting more compressed. You should see a good neurosurgeon, the sooner the better. I also want to know if there is any weakness in the legs. Taking a look at the revised and previous MRI will give an idea if the stenosis is increasing or not. Let me know about EMG reports too.

As for the facet block, I think you will need a good neurosurgeon's opinion if it will help now. Let me assure you about the reports you have read about on web. They are wrong. No one gets obesity with such a minute dose of steroids. You need to have consistently used it for a period of months to years, and that too daily. Pimples and PCOD can be taken care of and managed well without much problems when you have just taken a very small dose of steroid. You need to understand that this is a very focal procedure and it doesn't spread throughout the body.

But I think you should see a good neurosurgeon and get his opinion. Meanwhile please start taking prescription medications like Pregaba-M 75mg twice daily. This will decrease the numbness and help in healing the nerves. Take it for 4 weeks. Though initially it might induce mild drowsiness but eventually you will get over it and everything will be fine. Also take Dolo 650 mg thrice a day if pain is getting severe as I have mentioned earlier. If it doesn't work, you can also take a slightly stronger analgesic like Tab. Ultracet thrice a day. But you need to take an antacid too with that. Doing Interferential therapy and local ultrasound focussed on the pain region will help too.
I think now you must have realized how much it helps to build strong muscles. They will always help you in stabilizing the spine and decreasing chances of nerve compression etc. Once this problem is taken care of, please start doing exercises that strengthen your trapezius and neck strap muscles.
Do get back if you have any doubts.

Regards,
Pradeep
Above answer was peer-reviewed by : Dr. Pradeep Vitta
doctor
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Follow up: Dr. Pradeep Vitta (25 hours later)
I have previously forget to add some details in my MRI report:
Bony Spinal canal levels     AP diameter in mms
L1      15.5
L2      13.5
L3      14.1
L4      14.7
L4-L5      11.1
L5      13.9
L5-S1      10.4
And My EMG report also:
EMG report
N1: Peroneal – Right (MNC test)
Rec.: EDB
Temp. (Degree Celsius)
Stim site      Lat 1 (mS)     Lat 2 (mS)      Dur (mS)     Amp      Area
N1: Ankle      2.63      13.13      10.50     9.41mV     29.15 mVmS
N2: Knee      8.88      20.25      11.38     8.23mV     28.27 mVmS

Segment     Dist (mm)      Diff (mS)     CV (m/S)
EDB – Ankle     60      2.63      22.86
Ankle – Knee     370      6.25      59.20

N1: Peroneal – Left (MNC test)
Rec.: EDB
Temp. (Degree Celsius)
Stim site      Lat 1 (mS)     Lat 2 (mS)      Dur (mS)      Amp     Area
N1: Ankle      2.38      13.00      10.63     6.78mV     21.39 mVmS
N2: Knee      8.75      20.63      11.88     5.78mV     20.78 mVmS

Segment     Dist (mm)      Diff (mS)      CV (m/S)
EDB – Ankle     70      2.38      29.47
Ankle – Knee     350      6.38      54.90

N: Tibial – Right Rec: Soleus Muscle Stim: Pop fossa (H – Reflex Test)
M: 1 mV 7.5ms H: 1 mV
M-Lat (mS)      2.00
H-Lat (mS)      21.00
(H – M) –Lat (mS) 19.00
H-Ampl (mV) Trace: 10 0.99

N: Tibial – Left Rec: Soleus Muscle Stim: Pop fossa (H – Reflex Test)
M: 2 mV 7.5ms H: 1 mV
M-Lat (mS)      2.00
H-Lat (mS)      26.00
(H – M) –Lat (mS) 24.00
H-Ampl (mV) Trace: 10      1.14


Sir, my doctor didn’t say anything about the EMG report. Can you tell me if there are abnormalities seen in my report which was attached above? I have pain in lower back and sometimes the pain radiates till thighs when it is severe only. And I do have pain till my rectum and tailbone then few months of constipation and UTI along with the numbness if I sat for long time. Otherwise everything is manageable so far. I had knee pain last year in April suddenly with symptoms of snapping sound while walks, weakness at knees, pain was only unbearable while I bend my knees by sitting in the floor (when my weight pressures the knees) so I consulted an ortho doctor who said that I have discoid meniscus and gave me painkillers which didn’t work out for me. And I don’t know what had happened; my knee pain suddenly disappeared in this year January. After that I don’t have knee pain or knee weakness so far. Now my back pain spreads only till my thighs not to legs or knees.
Sir, I have few questions to be clarified. I need your opinion.
1.     Can you tell me why the EMG test was taken and what my EMG report says? Is there any abnormalities?
2.     After this problem, I feel that I cannot enter into marital life. This may affect my marital life and importantly the pregnancy for woman in future. Marriage is an advice able one or not?
3.     Apart from the two options (i.e.) surgery or undergoing steroid treatments. Is there anything else which can help me? I know that you have explained me about the temporary pain reliefs and treatments.
Thank you for your kind support and detailed answers for all my queries patiently. And I am signing off with this as my last follow up sir. Thank you once again.
Regards, XXXXXXX
doctor
Answered by Dr. Pradeep Vitta (19 hours later)
Brief Answer:
There is canal stenosis possibly causing cauda equina syndrome.

Detailed Answer:
Hi,

I have gone through your reports. The EMG is showing a significant decrease in the velocity of conduction of nerve impulses through the nerves in both legs. Specifically the S1 nerve also shows being affected in the H-reflex test. The AP diameter of the spinal canal shows stenosis/ shrinkage of the diameter which is the root cause for all the problems, like foot drop, pain and shock like sensation. These symptoms along with constipation and recurrent UTIs generally point to cauda equina syndrome. Which means you need to get it treated urgently. You are still in safe period as you don't have urinary leakage yet. Once you develop that, recovery of the nerves gets very delayed. So please consult a good neurosurgeon as soon as possible. Epidural injection also won't help that much now in my opinion.
A few questions that I have, did you have this only from 2013 or earlier too you had a few problems like a swelling in the lower back at birth? Did you have any previous fall or trauma? Any episode of urinary leakage? Are you able to feel touch sensation near the genitalia and perineal region?
As for pregnancy, it is difficult to tell at this stage. The extent of compromise of the nerves has to be checked with a good physical exam. However it is certainly possible but you need to take a lot of care during pregnancy as the ligaments become less taut during pregnancy and there may be recurrence of pain etc. So you need a good guidance of good neurosurgeon and an obstetrician when you get to that point. I am afraid nothing will help other than surgery. The rest of options are very temporary and don't address the root issue you are having, which is a mechanical problem. It won't go away with medications, it can only be managed with medications. Do not be scared of surgery if you have to undergo. Several people have experienced excellent benefits with it. Just in one day you can see the benefits. You need to discuss all this with a spinal surgeon as soon as possible. Meanwhile take the medications that I mentioned too with a doctor's prescription.

If you have doubts, do get back. Do not hesitate.

Regards,
Pradeep
Above answer was peer-reviewed by : Dr. Pradeep Vitta
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Dr. Pradeep Vitta

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What causes facet arthropathy?

Brief Answer: Need a few details about the lower back ache to recommend a regimen Detailed Answer: Hi, I have gone through your complaints and need you to elaborate on a few more details mentioned here before I suggest a line of treatment and, if your problem is serious or not. It all depends on the extent of symptoms. Since when has the pain been there; I mean describe from the initial episode, and then its history of progression or regression. Also does the pain just stay in lower back or does it go down the thighs and legs to the feet? Any weakness or numbness or tingling sensations in the thighs, legs, feet? I also want to know if you have any pain in your neck radiating to your hands too since the cervical spine MRI shows there is mild indentation on the cord. As far as the MRI report goes, it shows facet arthropathy, basically meaning the joints where two vertebrae stick to each has some inflammation. This can cause irritation to the nerve coming out and thus causing your problems. Now generally if the physical examination confirms the findings of the MRI, there is a very minor procedure called facet block injection, which in my opinion can take care of the problem. Now let me tell you what the injection is. Yes it contains steroids, but let me tell you that not all steroids are dangerous. They are dangerous depending on how long you take them and not on what dosage you take them. So certainly steroids are life saving when there is spinal cord injury and they are generally given once unless and until the pain recurs in which case it will recur after a period of 3-6 months and it is all variable. So a single shot of steroid will do you no harm, rather the benefits far outweigh the risks. Along with the steroid, they also will have minute amounts of local anesthetics which will numb the nerve irritation and thus benefit you. Traction has been proven to be not all that helpful but surely you can give it a try. Some find it helpful some don't. But one thing I would advise you to do once the pain dies down, is to regularly swim. Once you strengthen your back muscles and neck muscles, they get firm enough to hold all the vertebrae in position and thus defend the nerves from irritation and compression. You should do that only after the pain has gone down. Also I think you should start taking Tylenol for the pain, thrice a day if it is severe. If that doesn't help go for local ultrasound and interferential therapy which will relieve the pain temporarily. They are all non-invasive. I would also suggest to see a spine surgeon for his opinion. He would be in a better position to do the requisite physical exam and decide the best course as the physical exam dictates. Hope this helps, of course if you have any queries or clarifications, do get back here and I will clarify them for you. Regards, Pradeep