So Ross… has now experienced severe sciatica from a disc injury.
After bragging in the last blog post about being able to do what he wanted without an increase of symptoms despite a significant herniated disc creating a moderate amount of central canal stenosis, had an interesting week at the end of June.
Ross’ MRI from Dec ’23 shows moderate central canal stenosis. The obvious disc bulge is visible, and you can still see individual nerve roots (black and white specs within the green circle) as they travel down the spinal canal.
He had a little flare up of neural tension (tightness in his back with his legs stretched out in front of him) for a few weeks starting in May. He stopped climbing and tried to learn how to become an efficient swimmer (which actually increased his back pain initially, but improved mobility). It all seemed okay though, as his neural tension was starting to decrease.
The week before Ross’ “incident”, he was even feeling much better. He actually swam a mile on a couple of occasions that week with no increased pain, and he even forgot to take his anti-inflammatories the last couple days since things were feeling good. He did a little light yard work on a Sunday morning (mowing, and fiddling with sprinkler heads) with no pain.
When Ross sat down to eat some Cheez-Its (he has a 4 year old, so of course he house is filled with all the good stuff), his foot went numb…
And when he stood up, the numbness traveled up his lower leg…
He laid down, the numbness went away. Great! He could twist, and that felt good. Amazing!
He stood up – walked 30 feet – numbness returned. That’s not good. I couldn’t even tolerate getting into my home- made unloading device.
Trust me. My face did not look like this trying to get into this.
Ross laid back down, symptoms slowly decreased. And as this went on for the rest of the day, it progressively worsened…walking 30 feet turned to 0 feet, as symptoms started immediately upon standing up. He couldn’t sit, and lying on his back eventually was no longer comfortable. His wife tested his strength, and that seemed normal. Perfect, the nerve isn’t too impinged yet, but it is likely a progression of sciatica from a disc injury
This all started before 10am, it was now after 5pm and he was still trapped lying prone with 2 pillows under his stomach (he even ate some dinner in this position). At least a Xanax helped me take a brief nap here to pass the time. But I haven’t even got to hang out with my kid today…
He wondered what the heck the Emergency Department would actually do for sciatica from a disc injury…
As no one is injecting steroids into him on a Sunday evening which he thought would be the most direct course of care. Seeing his preferred neurosurgeon for a consultation would likely take weeks. Furthermore, getting to the hospital required being upright for a pretty long time, which was not the least bit appealing. As that was pretty much his only option, we went sometime after 8. Thank god we have a roommate and can just leave her with her.
On the way to the hospital his foot and leg pain progressed (of course).
But as he was waiting in the waiting room, he noticed a lack of control in his big toe and ankle eversion. Shit. Increasing weakness is nearing the worst case scenario. It is, at least, consistent with sciatica from a disc injury and localized to my right L5 Nerve Root only. The weakness hasn’t spread to multiple muscle groups, the pain hasn’t gone to my left leg, and most importantly, I haven’t peed or pooped myself… all those could be leading to a worst case scenario and require emergency surgery.
He could still hobble back to a room when summoned. Hell yeah. There is a gurney. I can lie down again.
Not too long after lying down, control to the great toe and eversion improved. Another positive sign there is a mechanical component and not just inflammation. It just kinda sucks that the mechanical component is gravity…
After 30-60 minutes of a brief consult with the PA and a tech starting an IV, the nurse came in with the good stuff. Dilaudid (hydroMORPHone), a steroid (Dexamethasone, which doesn’t last long in your system as far as steroids go) and an anti-inflammatory for the IV. Heaviness set in as soon as the Dilaudid hit, and things seemed to relax a bit. Finally…
15-30 minutes later, Ross could still feel the pain, but it didn’t matter too much. The nurse then came in to check on pain levels- he reported a 4-5/10- then gave him Valium. Valium may be the greatest thing ever created. All pain and leg symptoms instantly went away. Wow. How much of this pain was actually from me worrying about it? Talk about some real time central sensitization in action. I can’t believe how good my leg feels now. My leg isn’t grabbing when I move it. Lying on either side feels okay, but lying on my back feels pretty good. I’ll just stay here.
Sometime later the nurse comes in, “Hey… Doc said we could give you some more Dilaudid. How’s your pain? Would you like some?” My pain is pretty minimal, but I’m here, so why not? “Sure,” He replied. Enter heaviness.
Who knows how much later… Nurse comes in, “Okay we are going to send you home now with some Valium.” Hell Yeah, that for sure helped the most. “And we’ll send in a script for a steroid pack and some gabapentin today from the pharmacy”. Why didn’t I even consider oral steroids? Of course that is the easiest and best first step.
Now Ross, being a PT, is pretty anti-steroids for most musculoskeletal conditions.
His exceptions for injectable steroids are for: Frozen Shoulder (Cortisone injections are the only way to stop the shoulder from stiffening up), when they are used as a diagnostic tool (or to prolong the inevitable) before undergoing a total joint replacement, and epidurals for Sciata/radiculopathy. He did not care what-so-ever about going on systemic steroids and their potential side effects, as he had a clear and severe inflammatory condition that needed to be addressed. It is also only 6 days worth and is harmless for this length of use. This is a great first step.
Ross called his wife to come pick him up sometime after midnight.
He stood up and just walked out. How surreal. Just leaving a service, not paying, or scheduling a follow up. Wow, it is super pleasant outside. Where should I wait? Ohhh… this bench here surrounded by trees looks nice. Hey. I don’t have any pain in my leg right now. This is crazy. There is no pain driving home, lying in bed, or with falling asleep.
Of course this is the first night Ross’ 4 year old, Sophie, comes into his room to wake him and his wife up around 5:30 because she had a bad dream. Ross tried to get her out of the room, so his wife could sleep since she still had to work. Pain isn’t too bad up and walking. Sophie wants nothing to do with her dad. Frickin’ perfect. “Well Sophia, I’m going down stairs to watch some TV.” TV always works in this situation, please come down with me… oh no… the pain in my leg is returning. I need to lie down again, but first, Valium.
Once he was lying down, in a most obvious place to lie down, pain began to settle down again.
Sophie eventually came down to watch some TV, but she still hated her dad, and he had no idea why. Ross later found out her dream was about “daddy playing with a squishy, purple ball that he wouldn’t share with her”. She still reminds me that I need to share, despite our conversations about dream-real and real-real.
Now that Sophie had settled down, it was time to wait until 8am to call and make a neurology appointment, and 9am to pick up the most-needed steroids. When the Valium kicked in again, the pain subsided in weight-bearing, Ross could walk, but he still wished he had crutches. Sophie was off to school. Ross made appointments with Physiatry for a hopeful injection and a Neurosurgeon’s PA for a surgical consult before heading out on vacation. Driving didn’t feel bad for him, and he started taking oral steroids.
An appointment later that day with Jane at Alta helped relieve some neural tension. Not a big difference in strength, as there is likely too much compression on the nerve – still most likely from inflammation.
This was one of those situations that was all about the Steroids and Valium to get Ross through some severe sciatica from a disc injury despite his efforts to just manage it with physical therapy. Sometimes that happens when an inflammatory condition takes precedence over and amplifies the mechanical components of low back pain. We at Alta are equipped to help you tease out those conditions and make the appropriate referral out that may respond more to further medical interventions, like Steroids and Valium.
Steroids and Valium man, Steroids and Valium.
See our blog next week for how he managed the rest of the week…
Disclaimer: Valium is highly addictive and more restrictive for docs to prescribe than opiates. Ross only needed to take 1 at night for the next 2 nights, after that Monday.