Chronic low back pain

Low back pain due to spondylosis and degenerative disc disease
Short Summary

35 years old male. 3 years ago an episode of lumbar pain. After an X-ray test and lumbar spine MNR a disc herniation was diagnosed. Later on, disorders showed up sporadically, and 15 days ago, as a result of backache recurrence, the patient decided to carry out diagnostic deepening performing a new lumbosacral magnetic resonance and an electromyographic examination.
The MNR was consistent with spondylosis and degenerative disc disease. Worsening disc herniation both at L3-4 with left side herniation and L4-5 with right disc herniation. The EMG/NCS, showed chronic signs of denervation in right L5 (S1) segment.

Patient's Questions

1) Therapy suggested?
2) Activities that can be carried out and that can’t be carried out?
3) Do you advise a therapeutic or surgery approach?
4) Drugs recommended in case of pain?
 

Medical Background

35 years old male. No significant notable pathology in anamnesis.
3 years ago, symptomatic beginning of lumbar pain when the patient, spending a lot of time seated in his office, complained of pain in his back when standing up from the chair.
Following X-ray test and lumbar spine MNR a disc herniation was diagnosed, which in those days was not associated with lower limbs paresthesias.
The MNR medical report: “Paramedian median protrusion with right prevalence occurs at the L4-L5 intersomatic space, with moderate pressure effects on the dural sac and it slightly migrates upwards involving the armpit-shaped area of the right L4 root. No alterations of the spongious bone in the STIR sequences referable to edema. Spinal canal normal for morphology and dimensions. Degenerative notes involving L3-L4 and L4-L5 intervertebral discs with strong dystrophic reaction of the opposed endplates and depression of L4 anterior-superior limit due to disc intraspongious herniation. Signs of spondylosis. Spine straightening due to normal curvature loss.”

Later on, disorders showed up sporadically, therefore the patient didn’t pay particular attention to them.
On the contrary, about 15 days ago, as a result of backache recurrence, an injection of Voltaren and Muscoril was needed following which the pains completely disappeared.

The patient, however, decided to carry out diagnostic deepening performing a new lumbosacral magnetic resonance and an electromyographic examination, the reports of which are the following ones:
-  Lumbosacral magnetic resonance: “Presence of spondylosis phenomena more evident at the level of the distal segment of the lumbosacral spine. The spinal canal dimensions are within normal limits. Intersomatic discs L3-L4 and L4-L5 show reduced signal in T2 due to dehydration phenomena. At L4-L5 level, evidence of localized discal herniation in right median and lateral area that causes compression on the ventral dural sac. At L3-L4 level, detection of median protrusion of the intervertebral disc more towards left, resulting in moderate impression on the dural sac. Presence of Schmorl’s node at the level of L4 upper somatic limit on the anterior side. Normal the remaining intersomatic spaces of the spine segment examined”.

- Lower limbs EMG: "The examination has revealed signs of chronic neurogenic damage, without any current denervations, with right L5-(S1) distribution.”

On completion of the clinical picture, the patient carried out another lumbosacral spine X-ray recently which simply revealed “disc impressions involving the endplates analyzed.”
 

Expert's Opinion

To summarize the history, the patient is a 35 years old office worker, healthy otherwise, who started having low back pain 3 years ago. The pain was related to history of prolonged sitting with getting up from the chair. At that time the pain was axial only.
The ordered lumbar MRI at that time showed spondylosis and degenerative disc disease mostly in the L3-4 and L4-5 segments with right L4-5 disc herniation.
The pain was persisting on an on and off basis until four weeks ago, when the axial low back pain increased with lower extremities radiation, parasthesias and tingling. The pain is constant, fluctuating at a 1-8/10 VAS level. The pain increases with prolonged sitting and getting up from the chair. It improves in supine position and resolves with am injection of Voltaren with Muscoril.
No bowel or bladder symptoms. The patient is still able to function and continue attending work.
The physical examination findings reported, are limited to lumbar muscles tenderness.
The lumbar MRI, that was repeated, was consistent with spondylosis and degenerative disc disease. Worsening disc herniation both at L3-4 with left side herniation and L4-5 with right disc herniation (reports reviewed/images not available).
An EMG/NCS later, showed chronic signs of denervation in right L5 (S1) segment.

ASSESSMENT: A 35 year old male with history of chronic low back pain with a discogenic, spondylitic, radicular and myofascial components. The degenerative disc changes are progressing with increase in neuropathic symptoms.

PLAN (answering your questions):
1. No further diagnostic tests suggested. The patient may further strongly benefit from an evaluation by a pain specialist or neurologist to better define the physical findings and impairments.
2. Interventions:
a. The patient may benefit from a trial of lumbar epidural steroid injections. If these provide sufficient pain control not exceeding 3-4 procedures a year, surgery may be avoided or postponed.
b. An evaluation by a spine/orthopedic or neurosurgeon may be helpful if symptoms worsen. At this time the patient does not seem to be a surgical candidate, unless other treatment is not successful or not available for any reason (injections).

3. Pharmacologic:
a. The patient may benefit from using a NSAID (ibuprofen, naproxen, etodolac or other) on a regular schedule until symptoms improve and then as needed.
b. The patient may use muscle relaxants at night (Tizanidine, cyclobenzaprine, baclofen).
c. The patient may use neuropathic pain medications for his radicular pain. Choices may include: amytriptyline, nortriptyline, gabapentin, pregabalin, topiramate.
4. Rehabilitation therapy:
a. The patient would strongly benefit from a physical therapy course with core muscle strengthening.
b. He may continue his regular activities at home and work. Limitations include: no prolonged sitting, standing or bending. No strenuous activities and weight lifting more that 10-20 Lbs. (5-10 kg).
 

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