Appointments with Neurosurgery and Physiatry for Sciatica.
Ross had an easy going Monday after a pretty intense Sunday, as he still preferred to be flat. He was able to walk an unloaded mile after seeing Jane for her Magic.
Walking in my unloading device once again became a source of relief.
Tuesday Morning Ross woke up with a little feeling in his back and slight pain. This is a great sign and called Centralization. The days before there was no feeling in his back, not numbness, just indifference. There was also only buzzing in his foot – which was a pretty benign feeling compared to the pain he experienced the other day. Control of his foot was there – also good.
Physiatry for Sciatica
He had scheduled a Telehealth Consult with Dr. Jason Andrade at Spine West that AM. When they reviewed Ross’ MRI from 7 months ago, Dr. Andrade described his cord compression in my spine was considered “moderate” (they could see individual nerves), versus “severe” as the radiologist had described. I was also assuming there was some progression of my herniated disc as my left leg had more nerve tightness than 1 month prior and because of the sudden onset of severe symptoms.
Dr. Andrade doesn’t feel a repeat MRI is completely necessary since Ross’s symptoms are very localized to the R L5 nerve root. Sounds alright as I don’t want to spend extra money… I haven’t even seen my Emergency Department Bill yet…
Ross also doesn’t want surgery if it can be avoided, and Dr. Andrade has seen good improvements in strength after injections. Unfortunately, this appointment was over telehealth, so reflexes and muscle strength couldn’t be performed effectively. We had to document perceived strength (which at this time was how well can Ross control these motions).
Ross was actually able to schedule the injection in 2 days – just before he had planned to fly back home for vacation. He was psyched.
Ross walked another unloaded .75 miles on his treadmill that morning and work that day went pretty well. No real change in symptoms standing or sitting – didn’t need to lay down. All good signs. It actually felt good to be at work with a fairly consistent change of position. The only thing I had to change was making my patient’s pick up their weights, which is good for them anyways.
Neurology Appointment with a Neurosurgeon’s PA
The visit started out similarly as with Dr. Andrade: reviewing Ross’s History of Symptoms, reviewing the MRI which was also reported to be “moderate” compression, but he recommended a new MRI, as the other was over 6 months old. Makes sense, even though I don’t want to spend more money, my sudden change of symptoms seems to warrant a new MRI.
Then onto the physical exam which Ross was looking forward to documenting his weaknesses by testing his “myotomes” (or specific muscles that are controlled by certain nerve roots, so you know which level the pathology is at.
This was a bit brief.
Pressures were held for less than 1 second in the majority of muscles, other than Extensor Hallucis Longus (the muscles that lifts the big toe, and is controlled by L5. Really? You’re done? You had me take 2 steps on my toes and heels to test L4 and S1 – which my right calf did not feel like it should when I walked on my toes. That nerve root is also a level lower than L5. That would be a much bigger deal if that is affected.
Briefly testing muscle strength won’t differentiate between muscle weakness or nerve weakness.
It takes 10 whole seconds for neurogenic weakness to appear because the nerve will poop-out sooner than a muscle. In fact, muscle weakness will even improve by holding longer.
Multiple muscles at each myotome were also not tested. I would have liked to know what my evertors were feeling like, as they are another muscle innervated by L5, and functionally way more important than just lifting up my big toe. (The evertors, or peroneals, live on the outside of your shin and prevent you from rolling your ankle, let alone set up the whole lower extremity for better mechanics.)
The PA took reflexes, and they felt pretty normal for Ross. Huh. Hoffman’s was positive. Which can indicate a spinal cord entrapment in the cervical spine, but is also present normally in about 15% of people. I remember a time when I was testing it one morning on myself, it was positive, then I ate lunch, and it was negative after eating. I’ve also been fairly hyperreflexic my whole life.
In reporting the findings to Ross, the PA latched onto the apparent “hyperreflexia”.
They started by saying, “So, the reflexes could indicate a cervical myelopathy, which is a spinal cord compression.” Yeah, I know what myelopathy is, and the reason I like your presiding doctor is because he won’t over treat a cervical disc if it is asymptomatic. Hyperreflexia is one symptom of cervical cord compression. Apparently, you just disregarded my lack of widespread bilateral weakness, sensation changes, or having no loss of balance (which are the other signs/symptoms of cervical myelopathy).
The PA continued…
“The way to determine that is to look at your neck on MRI.” Wait, you are seriously still talking about my neck right now? Why the hell are you talking about this? There is a clear and present issue, probably between L4 and L5, and it’s probably pressing on my L5 nerve root. Don’t you think?
“Is that something you’d like to look into?” NO IT’S NOT SOMETHING I’D LIKE TO LOOK INTO! LET’S TALK ABOUT THE PART OF MY SPINE THAT SENT ME TO THE ED 3 DAYS AGO!
“We could do a microdiscectomy, this is how it is done, but we would need the updated MRI and flexion and extension films to look for excessive movement between L4/5.” He continued to say an injection is a good idea, but weakness wouldn’t improve with an injection. Huh. That’s less than ideal, but also fairly expected for you to say.
Work after that appointment also went without hassle.
The Epidural
The process of an epidural is pretty benign and the hallmark of Physiatry for Sciatica
The most pain is from removing the first needle that numbs the skin. And even that needle mostly just feels like a dry needle in the paraspinals. Then, Dr. Andrade inserted the blunted needles that deliver the medication. The interesting thing about this though is even though the L5 nerve root is inflamed (the orange nerve root), there isn’t enough room to get there because the ilium sits in front of the foramen (green circle down below). So, the docs have to go in through L4 (blue arrow), and allow the medication to drop down to the L4/5 disc and to the L5 nerve root from inside.
Click Here For More Reading on Epidurals
Ross was super confused when he initially saw his image below, until he read up on it. You can see the needles and contrast dye entering the foramen at L4 and the contrast. With the dye, they are looking for it to start dropping down into the spinal canal. When they see that, they know the needle is in the right spot and can inject the medication.
Bonus Points if you can find the extra bit of bone that I think contributed to my disc herniation.
Two small band-aides later, it was all said and done in 15 minutes. Then Ross just had to wait for 2-3 days for the medication to kick in to see how much it will benefit. In the meantime he will continue taking his oral steroids and gabapentin.
Ross was able to clarify a discrepancy about strength with Dr. Andrade
Dr. Andrade clarified there are 2 types of neurogenic weakness. There is the obvious “damage to the nerve” weakness that should likely be taken care of with surgery to prevent further damage. This weakness usually presents weeks after the onset of symptoms due to muscle atrophy. A Conduction Block is the second type of weakness, which is lesser known, but more common.
Think of how nerves work like how a toilet works:
You send a signal through a nerve, that signal reaches the muscle, the muscle works – there is no stopping it. You flush a toilet, the bowl fills up, the water drains – there is no stopping it.
If you block the conduction with some inflammation and a herniated disc that increases the pressure on the nerve, that signal may end up not going through. Or if the signal does go through, the nerve’s ability to reset its charges has slowed. That slows the frequency of electrical impulses, and causes the muscle to not respond as vigorously. (That is why it takes awhile for neurogenic weakness to show up as well). Ross’ 4-year-old deposits the biggest turd you’ve ever seen into the toilet: you try flushing, but that bowl will fill up, and keeps filling up, and doesn’t go down. This usually requires further intervention of a plunger to reduce the obstruction.
The conduction block weakness usually occurs acutely:
It comes on suddenly and, it will be more mechanical in nature (you can turn the symptoms on and off). Dr. Andrade believed Ross’ weakness through his subjective reporting of how easily he could control my L5 myotomes. That was the best objective measure up until this point. Inflammation can also play a role by filling up extra space with fluid. Inflammation may also appear more permanent since it will not respond to a mechanical stimulus. Oral and injectable steroids are there to combat these significant inflammatory reactions, while your favorite NSAID will help with mild inflammation. An EMG (also at Spine West) can also help determine which kind of neurogenic weakness is present.
For further medical intervention and testing, go see Dr. Jason Andrade. He is amazing, patient, and has the best bedside manner I’ve seen in a doctor. Dr. Andrade has gone above and beyond to answer my questions. He is even digging out the research he collected on disc healing to share with me (the research out there is pretty poor, and sifting through it is incredibly time consuming and frustrating). Dr. Andrade also trained at Spine West. If he is booked out, I have full faith that the others there will take care of you as well. We at Alta have also worked extensively with Spine West’s providers as Physical Therapy and Physiatry is the best first line of defense in those with back pain.
Stay Tuned for Ross’ story on noticing more functional weakness, and what he did to help in the short term…